This article explores the experience of ex-rebels who have become humanitarians in the eastern Democratic Republic of the Congo. It describes how rebel-cum-humanitarians navigate a turbulent political environment, integrating the knowledge they acquired through military experience into a career in the humanitarian sector. 'Distinction' between combatants and humanitarians remains central to the humanitarian imaginary. However, rebel and humanitarian spheres are interlinked by individuals who do not just broker relationships between the two, but also move between them. They walk a tightrope: their rebel past is seen as a threat to performing a 'neutral' humanitarian identity, but at the same time, it constitutes a resource in brokering access with armed groups. Despite a focus on performing principles, humanitarian agencies in practice draw on their employees' savoir faire which is sometimes gained through rebel experience -the very identity deemed antithetical to a humanitarian status. This research was funded by the ESRC Doctoral Training Programme and the St John's College Oxford 450th Anniversary Fund Scholarship. I would like to thank David James, Louisa Lombard, Faith Cowling and Tom Scott-Smith, as well as the three anonymous reviewers, for their insightful feedback on earlier versions of this article. Finally, I am indebted to everyone who took the time to talk to me, and in particular to Faustin, Imani and Gloire for their patience and generosity. Any errors remain my own. 1. All names of individuals have been changed.
IntroductionThis study aimed to determine whether the COVID-19 pandemic had an impact on the number of people seen at public facilities in Uganda, the Democratic Republic of the Congo (DRC) and Sierra Leone for essential primary healthcare services.MethodsThe number of weekly consultations for antenatal care (ANC), outpatient (OPD), expanded programme on immunisations (EPI), family planning (FP) services and HIV, for the period of January 2018-December 2020, were collected from 25 primary healthcare facilities in Masaka district, Uganda, 21 health centres in Goma, DRC, and 29 facilities in Kambia district, Sierra Leone. Negative binomial regression models accounting for facility level clustering and season were used to analyse changes in activity levels between 2018, 2019 and 2020.ResultsWe found no evidence that the COVID-19 pandemic affected the number of OPD, EPI or ANC consultations in Goma. Family planning consultations were 17% lower in March-July 2020 compared to 2019, but this recovered by December 2020. New diagnoses of HIV were 34% lower throughout 2020 compared to 2019. Compared to the same periods in 2019, facilities in Sierra Leone had 18-29% fewer OPD consultations throughout 2020, and 27% fewer DTP3 doses in March-July 2020, but this had recovered by Jul-Dec. There was no evidence of differences in other services. In Uganda there were 20-35% fewer under-5 OPD consultations, 21-66% fewer MCV1 doses, and 48-51% fewer new diagnoses of HIV, throughout 2020, compared to 2019. There was no difference in the number of HPV doses delivered in 2020 compared to 2019.ConclusionsThe level of disruption appeared to correlate with the strength of lockdown measures in the different settings and community attitudes towards the risk posed by COVID-19. Mitigation strategies such as health communications campaigns and outreach services proved important to limit the impact of lockdowns on primary healthcare services.Key messagesWhat is already known on this topicThe COVID-19 pandemic and the response measures put in place caused disruption to the provision and utilisation of primary healthcare services worldwide.What this study addsWe document that the COVID-19 pandemic had a varied impact on different services in three distinct settings on the African continent. The extent that the pandemic impacted services correlated with the stringency of the lockdowns, community perceptions of the level of danger posed by the pandemic and communities’ prior exposure to Ebola epidemics and concomitant response measures.How this study might affect research, practice, or policystrategies such as communication campaigns and outreach services limited the impact of lockdowns on essential services and would be valuable strategies to implement in future epidemics.
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