SUPPORTING LOCAL HEALTH CARE IN A CHRONIC CRISIS MANAGEMENT AND FINANCING APPROACHES IN THE EASTERN DEMOCRATIC REPUBLIC OF THE CONGO Dennis Dijkzeul and Caroline Lynch Roundtable on the Demography of Forced Migration Committee on Population and Program on Forced Migration and Health Mailman School of Public Health Columbia University THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by a grant to the National Academy of Sciences and the Joseph L. Mailman School of Public Health of Columbia University by the Andrew W. Mellon Foundation. Any opinions, findings, conclusions, or recommendations ex- pressed in this publication are those of the authors and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number 0-309-10038-0 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Research Council. (2006). Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Re- public of the Congo. Dennis Dijkzeul and Caroline Lynch. 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The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the govern- ment, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org ROUNDTABLE ON THE DEMOGRAPHY OF FORCED MIGRATION 2004-2005 CHARLES B. KEELY (Chair), Walsh School of Foreign Service, Georgetown University LINDA BARTLETT, Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta RICHARD BLACK, Center for Development and Environment, University of Sussex STEPHEN CASTLES, Refugee Studies Centre, University of Oxford WILLIAM GARVELINK, Bureau of Humanitarian Response, U.S. Agency for International Development, Washington, DC ANDRE GRIEKSPOOR, Emergency and Humanitarian Action Department, World Health Organization, Geneva JOHN HAMMOCK, Feinstein International Famine Center, Tufts University BELA HOVY, Program Coordination Section, United Nations High Commissioner for Refugees, Geneva JENNIFER LEANING, School of Public Health, Harvard University NANCY LINDBORG, Mercy Corps, Washington, DC CAROLYN MAKINSON, Andrew W. Mellon Foundation, New York SUSAN F. MARTIN, Institute for the Study of International Migration, Georgetown University W. COURTLAND ROBINSON, Center for Refugee and Disaster Studies, Johns Hopkins University SHARON STANTON RUSSELL, Center for International Studies, Massachusetts Institute of Technology WILLIAM SELTZER, Department of Sociology and Anthropology, Fordham University PAUL SPIEGEL, Global Coordinator on HIV/AIDS, United Nations High Commissioner for Refugees, Geneva RONALD WALDMAN, Joseph L. Mailman School of Public Health, Columbia University ANTHONY ZWI, School of Public Health and Community Medicine, University of New South Wales BARNEY COHEN, Director, Committee on Population ANA MARIA-IGNAT, Senior Program Assistant* ANTHONY MANN, Senior Program Assistant** * Until November 2004 ** Since November 2004 v COMMITTEE ON POPULATION 2004-2005 KENNETH W. WACHTER (Chair), Department of Demography, University of California, Berkeley ELLEN BRENNAN-GALVIN, School of Forestry and Environmental Studies, Yale University ANNE C. CASE, Woodrow Wilson School of Public and International Affairs, Princeton University JOHN N. HOBCRAFT, Population Investigation Committee, London School of Economics CHARLES B. KEELY, Walsh School of Foreign Service, Georgetown University DAVID I. KERTZER, Department of Anthropology, Brown University BARTHELEMY KUATE-DEFO, Department of Demography, University of Montreal CYNTHIA LLOYD, Population Council, New York DOUGLAS S. MASSEY, Department of Sociology, University of Pennsylvania THOMAS W. MERRICK, Population and Reproductive Health, World Bank RUBEN G. RUMBAUT, Center for Research on Immigration, Population, and Public Policy, Department of Sociology, University of California, Irvine JAMES W. VAUPEL, Max Planck Institute for Demographic Research, Rostock, Germany ROBERT J. WILLIS, Institute for Social Research, University of Michigan, Ann Arbor BARNEY COHEN, Director vi Preface n response to the need for more research on displaced persons, the Committee on Population developed the Roundtable on the Demog- Iraphy of Forced Migration in 1999. This activity, which is supported by the Andrew W. Mellon Foundation, provides a forum in which a diverse group of experts can discuss the state of knowledge about demographic structures and processes among people who are displaced by war and politi- cal violence, famine, natural disasters, or government projects or programs that destroy their homes and communities. The roundtable includes repre- sentatives from operational agencies, with long-standing field and adminis- trative experience. It includes researchers and scientists with both applied and scholarly expertise in medicine, demography, and epidemiology. The group also includes representatives from government, international organi- zations, donors, universities, and nongovernmental organizations. The roundtable is organized to be as inclusive as possible of relevant expertise and to provide occasions for substantive sharing to increase knowl- edge for all participants, with a view toward developing cumulative facts to inform policy and programs in complex humanitarian emergencies. To this aim, the roundtable has held annual workshops on a variety of topics, in- cluding mortality patterns in complex emergencies, demographic assess- ment techniques in emergency settings, and research ethics among conflict- affected and displaced populations. Another role for the roundtable is to serve as a promoter of the best research in the field. The field is rich in practitioners but is lacking a coher- vii viii PREFACE ent body of research. Therefore, the roundtable and the Program on Forced Migration and Health at the Mailman School of Public Health of Colum- bia University have established a monograph series to promote research on various aspects of the demography of forced migration. These occasional monographs are individually authored documents presented to the roundtable and any recommendations or conclusions are solely attributable to the authors. It is hoped these monographs will result in the formulation of newer and more scientifically sound public health practices and policies and will identify areas in which new research is needed to guide the devel- opment of forced migration policy. This monograph has been reviewed in draft form by individuals cho- sen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making the pub- lished monograph as accurate and as sound as possible. The review com- ments and draft manuscript remain confidential. Ronald J. Waldman of Columbia University served as review coordi- nator for this report. We wish to thank the following individuals for their participation in the review of this report: Christopher Schwabe, health and public finance economist at Medical Care Development International, and Steven Hansch of the Institute for the Study of International Migration, Georgetown University. Although the individuals listed above provided constructive comments and suggestions, it must be emphasized that responsibility for this mono- graph rests entirely with the authors. This series of monographs is being made possible by a special collabo- ration between the Roundtable on the Demography of Forced Migration of the National Academies and the Program on Forced Migration and Health at the Mailman School of Public Health of Columbia University. We thank the Andrew W. Mellon Foundation for its continued support of the work of the roundtable and the program at Columbia. A special thanks is due Carolyn Makinson of the Mellon Foundation for her enthusiasm and significant expertise in the field of forced migration, which she has shared with the roundtable, and for her help in facilitating partnerships such as this. PREFACE ix Most of all, we are grateful to the authors of this monograph. We hope that this publication contributes to both better policy and better practice in the field. Charles B. Keely, Chair Roundtable on the Demography of Forced Migration Ronald J. Waldman, Member Roundtable on the Demography of Forced Migration Director, Program on Forced Migration at the Mailman School of Public Health of Columbia University