When MSF opened the Dubie project in May of 2005, things were very different then they are now.
The Congo was slowly starting to emerge from five years of bloody war that cost the lives of around 4 million and displaced millions more. A fragile peace blanketed the country that had slowly deteriorated under a 30-year dictatorship. All services had essentially ceased to exist and the Congo was characterized by a dysfunctional health care system, a complete lack of roads, a high level of corruption and a population facing a humanitarian crisis where all health indicators (including mortality) were much higher than what MSF would class as a typical “emergency”.
MSF Dubie Opens
It was under these conditions that MSF opened Dubie. During the first year of operations, the Congolese army launched a massive offensive in an area still controlled by Mai-Mai militia and MSF saw over 20,000 internally displaced people (IDP) arrive at our doorstep. Following the surrender of the Mai-Mai chief Gedeon in 2006, the security situation has continued to improve and the majority of these IDPs have since returned home. We have slowly seen an increase in the presence of Ministry of Health staff in all of our supported health facilities and there has been a gradual shift from a humanitarian crisis to a developmental one.
While war continues to rage in the Eastern part of the country (in the North and South Kivu provinces), there is no longer war in Katanga. Everyone is poor, no one has access to health care and we seem to be providing a service that really should be coming from the government. I now have a hard time explaining why we are only operating in Dubie and not in the next heath zone. Through an intensive drilling program, the water and sanitation situation has improved and we haven’t seen cholera for over 2 years.
So MSF is left with two choices here in Katanga. We either have to expand our operations – and our Mandate! – and venture into what could only be described as developmental activities; or we stick true to the mandate of MSF as a medical organization that provides emergency humanitarian relief and we handover our activities.
In the end, we have decided to go with the second option and are in the process of preparing the handover to our two project partners; the Congolese Ministry of Health and the Catholic Sisters.
The Catholic Sisters have been present in Dubie for over 50 years and have been running the local health center and maternity for just as long. They also have a huge convent, a beautiful church and the largest schools in Dubie. While our mandates do not necessarily align, it is safe to say that the Sisters are motivated (and now well trained with a fully function health center), have the confidence of the local villagers, some access to funds and will be around for a long time. With all things are considered, they are a pretty good handover partner.
The presence of Ministry of Health (MoH) staff has been slowly increasing over the past few years and MSF has invested a lot in both their facilities and the development of their staff. While the presence of staff is a big first step, the government still lacks the means to purchase drugs, has difficulty getting the drugs to the field and does not always have the means to pay their staff. In our case, the MoH will take over most of our current operations – in cooperation with the Sisters – and only a few of our services (our feeding center and HIV programs) will be dropped.
MSF will donate most of our equipment and will also leave a 3 month drug supply to help get our handover partners up and running. Regardless, both partners will install a cost recovery system and while $2 for a delivery and $30 for a C-Section doesn't seem like much, it will surely exclude the most vulnerable populations from access to health care.
Nothing is Perfect...
This is the reality. MSF opens a project knowing that at some point we will eventually pack up and go home. Knowing when to open is pretty easy. There is some sort of crisis – war, displacement, outbreak, disease – that results in an increase in mortality to a point that is seen as unacceptable for MSF. If the numbers are there, we open…regardless of how hard with think it may be to close down the road.
While present, we provide the best care that we possibly can for each patient that comes to our health centers and hospitals. We do this in the name of medical ethics, knowing all too well that the overall level and ultimate access to care will drop after the departure of MSF.
Deciding when to close is always less clear. The medical needs are often still present and our operations still have a meaningful impact. However, it is no longer an acute humanitarian crisis, the security situation is stable and other actors may be present and able to take over.
Dubie is no different. The medical needs are definitely present and our medical teams save lives each and every day. But there is no war and the IDPs have all gone home. People are poor and access to health care is limited, but the health indicators are getting better and poverty alone is not enough to justify an intervention. The Sisters are here and ready to take over. The Ministry of Health is moving in the right direction and needs to step up and start taking full responsibility for the health of the nation’s population.
…nothing is perfect and closures are always a bit messy but it is time for MSF to move on to where our operations are more in line with our mandate as an emergency humanitarian relief organization.