Paris, 27 May 2021
As part of our series of interviews with human rights defenders on the impact of COVID-19, we interviewed Mr. Maurice KASONGO WA BONDO. Deputy Secretary to the National Youth Committee of the Solidarity Union of Nurses of the DRC, who participated in our online training on ESCR in April-May 2021.
What was the situation of the right to health before the pandemic, including the challenges?
The situation :
- Dehumanisation of the services and precarity of the healthcare provided;
- Insufficiency of healthcare facilities (a total of 250 General Reference Hospitals covering a territory of 2 345 000 Km2 and serving a population of more than 80 million people);
- The existing health facilities (dating back from the colonial era) are obsolete and lack equipment;
- Worsening of the epidemiological situation and re-emergence of disease outbreaks that were previously under control (Cholera, Ebola, Shikungunya…) and emergence of new pathologies;
- Increased mortality rate due to clandestine abortions.
The causes of this situation:
- Insufficiency of the financial resources allocated to the health sector (approximately 7% of the national budget which is far from the 15% target that all African countries had set in Abuja in 2001);
- The funding of the health sector is to a large extent dependent on external contributions and cost-recovery from patients (up to 70% of the operating costs)
- Disarticulation, inequalities and inefficiency of the system
- Anarchical exercise of the healthcare activities
- Dysfunction in the laboratory network which prevents the early detection of epidemics
- Data collected is often unreliable
- Demotivation among health workers who are often under-paid and suffer discrimination and inequalities (favouritism towards doctors at the expense of other medical professionals, such as nurses);
- The healthcare system is very bureaucratic with 65 Directions out of which 52 are in charge of specialised programmes;
- A great number of medical professionals (physicians, nurses, midwifes, technicians, administrative staff) are not registered and have been working for years (in some cases even more than 4 years) without receiving a salary or a risk premium;
- Lack of objectivity in the management of human resources and lack of transparency in the management of financial resources;
- Lack of subsidies from the State for public healthcare facilities;
- Corruption, misappropriation, favouritism, nepotism and other anti-values coming from the government at all levels;
- Insalubrity of hospitals and health centres;
- Legal vacuum on vaccination and reproductive health (DRC has ratified the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa, however to this day there were no concrete measures to implement this Protocol and in particular to authorise medical abortion as stipulated in article 14 of the Protocol).
This situation and its root causes have exacerbated due to the lack of effective supporting measures to facilitate the exercise of the right to health by all citizens and the small fraction (7%) of the national budget allocated to the health sector.
Article 12 of the International Covenant on Economic, Social and Cultural Rights recognizes the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. DRC has ratified this treaty in 1976 and has confirmed its will to respect this right by incorporating it in its 2006 Fundamental Law, which was modified and amended in 2011.
However, even though this right has been incorporated in domestic law, the exercise of the right to health has always faced several challenges. Since its independence in 1960, DRC has demonstrated its respect for the right to health by creating public healthcare facilities and ensuring the regulation of the health sector. In order to fulfil its obligations, several declarations were made by different governments, including the last declaration made by H.E Felix Antoine TSHISEKEDI, the President of DRC, promoting the universal healthcare coverage.
Sadly, these laws and declarations are not followed by concrete measures and actions to allow the fulfilment of this right that continues to this day to face several challenges. The most serious challenges include the incapacity of health services to offer quality healthcare which responds to people’s needs; lack of equity in the healthcare system; and the cost of the health services which remains to this day extremely high for a population that is largely poor and unemployed.
Despite the promulgation of the Law 18/035 of 13th December 2018 establishing the fundamental principles for the organization of Public Health and promoting the idea of "health for all and by all", we observe that to this day the implementation of the right to health faces several other obstacles and challenges, notably:
- Insufficiency of health facilities (a total of 250 General Reference Hospitals covering a territory of 2 345 000 Km2 and serving a population of more than 80 million people). In the majority of the rural and peri-urban areas, such as Kasumbalesa, Walikale, Musokantanda, there are no hospitals nor health centres.
- Lack of operating costs in the public healthcare facilities.
- There is a great number of private healthcare facilities which provide services that are extremely expensive.
- The majority of the population works in the informal sector and does not have any social protection.
- In theory, those who have employment contracts or even better, those employed by the public sector have access to health mutual or benefit from free healthcare. In reality, this is not so easy and verifiable: the majority of the employees are served by healthcare facilities that are often ill-equipped.
- To access quality healthcare, you need to have enough money because even though there are public healthcare facilities, it is always the patient or his/her family that covers the total cost of the healthcare services.
- The geographical remoteness is another major problem. Patients often have to travel long distances (as long as 500 to 2000km) or even travel to another country in Africa or Europe to find a specialist. (Currently, in DRC there are specialists only in the big cities, including Kinshasa, Kisangani et Lubumbashi. Outside of these three cities, it is very difficult, even almost impossible to find a specialist in cardiology, gynecology and obstetrics, reanimation, nephrology, epidemiology, paediatrics, ophthalmology, etc.)
- The majority of the health structures (health centres, clinics and health posts) in rural areas are illegal and the care provided there is of unreliable quality. The medical staff is not qualified and unsafe practices are also used.
- The public healthcare structures have a lot of staff who are not registered and do not receive salaries nor risk premiums. Those who do receive salaries are not even able to cover their basic needs with what they earn.
- The inadequacy of the healthcare infrastructures built in the 1950s.
- Lack of equipment necessary for the provision of adequate care.
- Lack of medications in almost all public hospitals. Even in those cases when the hospital is able to provide the medication, the patient is always required to pay for it at exorbitant price. The patient is always required to pay for all medicines and sometimes for some medical materials (some patients are even asked to cover the cost for the fuel for the generator in case of power cut so that they can receive healthcare).
- What is really bad is that even if you are admitted in a public healthcare facility, you will be required to pay hospitalisation fees which include cost of stay, cost of medical services, cost of nurse services, the cost of laboratory tests, sanitation costs, operating costs, etc. The patient has to pay all these hospitalisation fees and cannot leave the hospital without paying the invoice (there are families who have been detained in hospitals for long periods between 3 and 9 months because they had not paid even though those are public hospitals).
Inequalities and discrimination in the health system
Another major challenge are the inequalities and the discrimination in the provision of health services which translates in treating better those who are wealthy and neglecting those who are not. Other than that, there are also inequalities in the way medical professionals are treated (some categories, such as doctors, have a lot of privileges et premiums at the expense of other categories, including nurses who are often marginalised, ignored and receive premiums equivalent of 1/10 of those received by doctors).
How this situation was exacerbated by the COVID-19 crisis?
The situation has further exacerbated due to the COVID-19 pandemic in the sense that the majority of the general reference hospitals lack adequate laboratories, reanimation rooms, medical devices for oxygen-therapy. In addition, they experience recurrent power cuts and the medical staff do not have personal protection equipment which means that they have to work without protection and easily get infected and then transmit the virus to their families (this is what happened in the NGALIEMA clinic in Kinshasa where 10 nurses got infected).
To make it worse, the majority of all these medical professionals who work without protection did not even receive any additional premiums or motivation. A significant number of medical staff continue working assuming the greater risk posed by COVID-19 without being registered and without having a risk premium.
The lack of financial means and the lack of solid social protection systems have also made the exercise of the right to health even more difficult during the COVID-19 pandemic.
How are COVID-19 patients treated?
Being exposed to a greater risk and demotivated, healthcare workers distrust and try to avoid COVID-19 patients. This means that the patients are hospitalised but they do not receive proper care and food which leads to their health deteriorating or they just decide to leave the facility and return to the community even thought they are still sick.
How the threat of Ebola exacerbated by the COVID-19 crisis has impacted the access to basic healthcare?
The threat of Ebola which appeared in the east of the country in 2019 amplified by the emergence of COVID-19 and combined with the poor treatment of patients have resulted in a significant decrease in the number of people visiting hospitals and health centres during this period due to the mistrust among the population and fear that if they go to a hospital, they can be tested positive for COVID-19 or get infected while there and be detained at the hospital in bad conditions and exposed to risk of developing other diseases and epidemics.
The conditions of hospitalisation remain precarious, the insalubrity is visible, especially in public healthcare facilities which are deprived of enough resources to operate and ensure their viability and properly treat the patients.