Ailing health system needs cure

Adults and children lie on a concrete floor between steely skeletons of beds that once had mattresses in the Isangi public hospital. A man stares into the void, close to death. A nurse tries to give a woman an injection using a needle that has been used several times, and will continue to be used for as long as the patient can come up with the money to pay for the medicine. The collapse of their health system horrifies Congolese. "It's disgusting. The medical team helps out in emergencies," Dr Jean-Robert Tshimanga, the hospital director, said "but if they [patients] have no money what can we do? Nature will take its course." Tshimanga has two brothers working in neighbouring Zambia. He wants to join them as soon as he can. "There is no future here," he said. Isangi hospital, 1,000 km east of the capital, Kinshasa, was built in 1926 by the Belgian colonial administration. It is one of about 500 hospitals in the Democratic Republic of Congo, 80 percent of which were built during the colonial era and managed by religious organisations. When the DR Congo's former president Mobutu Sese Seko came to power in 1965, he nationalised the health system and almost the entire structure fell into decay. Conflict in the mid-1990s only made it worse. Dr Lokongo Nzeya Abe was once director of hospitals in the DR Congo's health ministry. He now works as director of programmes for the United Nations World Health Organization (WHO) in Kinshasa. "The situation in 200 hospitals in the country is catastrophic," he said. Pay or die

The poorest people can expect little help in the public hospital of Kisangani.

About 30 per cent of the DR Congo's hospitals are still run by churches, 10 per cent by companies, while the rest are still under state control. Isangi hospital's pathology laboratory is devoid of chemicals; its operating theatre has almost no surgical equipment. Surgical tools and hospital aprons have to be sterilised over a fire. According to Tshimanga, the hospital's director, it is more than two decades since the hospital had any maintenance work done on it. WHO's programme director in Kinshasa, agrees. "When you go to a government hospital, you find no medicine, and the staff come in at 10 and leave at noon," said Nzeya Abe, adding a French phrase of total frustration: "tout est foutu" – "it's a complete mess". In recent years, the DR Congo's public health system has slid backwards. The country used to have a centralised pharmaceutical supply agency, but no longer does. In many hospitals patients have to queue for hours until they get to see a doctor – and they can only see one if they can pay for the consultation themselves. The 60 nurses and three doctors in Isangi hospital have not received their salaries since 1996, when troops from Uganda and Rwanda, as well as Congolese rebels, ravaged the area. In any case, Tshimanga could only expect the equivalent of just US $40 a month. And so the doctors at the hospital charge 250 Congolese francs (60 US cents) a consultation, and share this meagre income at the end of the month with the nurses. Patients without money often end up in the graveyard. The DR Congo's health system is seriously ill, and urgently requires intensive care. Forgotten diseases return "The main reason for the disastrous state of the health system is bad governance," said Nzeya Abe. This may be more succinctly described as corruption. At the end of May news emerged that $4 million had been lost at the ministry of health – almost half the entire health budget, or four to five percent of the country's national expenditure. "The money was officially invested but the hospitals never received anything," Nzeya Abe pointed out. "What actually ends up where it should, is less than half of what is allocated." As a result many curable diseases have returned with a vengeance: tuberculosis, typhoid, diarrhoea, intestinal parasites, leprosy and malaria – many of them waterborne, spread through unsanitary conditions. In Isangi and many other parts of DR Congo, deadly sleeping sickness trypanosomiasis, commonly cured with arsenic, was all but forgotten after being eradicated in the 1960s. Now it is back and threatening to kill whole villages. The NGO Medecins Sans Frontieres (MSF) Belgium runs a sleeping sickness research programme and treats people with new medicines. According to Tshimanga, "whole communities would have been wiped out" by the deadly disease without the MSF programme. Bypass the government

No money for medicine: The health system is in a state of total collapse. Father and child in Isangi hospital.

In recent years the WHO, the World Bank and NGOs have taken over most of the Congolese government's responsibility for the health sector. The UN Children's Fund (Unicef) has been providing free medicines, and the World Bank has funded the rehabilitation of hospitals. "You have to avoid the government," said Dr Jean-Pierre Manshande, project director at the World Bank in Kinshasa. The World Bank, like most other donors, channels millions of dollars in project money through international NGOs, to make sure that the money does not disappear into the pockets of officials. Over the next four years the main donors - the World Bank, the African Development Bank, the US Agency for International Development (USAID), the European Development Fund and the WHO - will inject more than US $700 million into the ailing health system. This amounts to about three dollars per person, per year, sufficient in other developing countries, said Dr Nzeya Abe. But whether the health system will receive the cure it needs depends to a large degree on the next elections. "It will take 10 to 15 years until things start changing, if we start to work now. But we need to get a parliament that says no to the way things are run at present," said Nzeya Abe. Patients as hostages For many of the patients in the public hospital in Kisangani, capital of Oriental province, this may be far too late. After fighting in the city in 1996, the hospital was abandoned. Belgian Technical Cooperation and the World Bank have revived eight of the hospital's existing 24 blocks. The hospital still lacks an intensive care unit and there is no anaesthetic equipment. The ambulance is without wheels, and a shortage of latex gloves means that the nurses are often exposed to disease. Five technicians have died from cancer due to exposure to radiation in the X-ray facility – a protective apron is urgently needed. "Sometimes we don't even have thread for sutures," said hospital director Aelar Lufungola. Sometimes, patients at his hospital are literally held hostage until they can pay for the treatment they received. "We can't carry on doing this," he said, "people know this." People also know that treatment in public hospitals should be free, and often dump relatives terminally ill from AIDS in public hospitals because of this. According to Lufungola, 80 percent of all in-patients are infected with HIV. "Many are staying on and are a heavy burden for our hospital." Ghost workers

Forgotten killer: An injection of arsenic medicine for a toddler suffering from sleeping sickness.

Ghost workers are another problem. For the 130 beds currently in use, there are 136 nurses on the payroll. According to Lufungola, "60 percent should have already retired." Many of the older nurses on the payroll stay at home while the younger ones do all the work. This situation is common right across the DR Congo's public services; retirement payments dried up years ago. "By removing all the ghost workers, we could raise the average salary from $10 to $50 a month," calculated the World Bank's Manshande. For the nurses this is little comfort. Marie Abeli, 32, has been working at the hospital since 2003. She does not even know what her official salary should be. She receives some money from patients' fees, and earns more by knitting children's clothes during quiet periods at work. The Kisangani hospital's nurses have gone on strike, but to no avail. Asked what she expects from the upcoming elections, Abeli replied: "Politicians only make promises." Nzeya Abe thinks he knows how to treat the ailing health service: "Give the management of government hospitals back to private organisations." [Countdown in Congo]