In a regional context, the health care system established to meet these challenges appears impressive, at least on paper, although the UN estimates that only 50 percent of the population had access to health care in the early 1990s (see table 9, Appendix). The ratio of physicians to population in the early 1990s was claimed to be approximately one per 14,000, markedly higher than in neighboring countries such as Rwanda (one to 35,000) or Burundi (one to 45,000), for example. The ratio of nurses to population was estimated as approximately one to 1,900, spectacularly higher than the sub-Saharan African average of one to 45,000. Average population per hospital bed was approximately 700, a better rate than neighboring Burundi's 850, for example.

In theory, the nation is divided into health zones, each covering a population of 100,000 to 150,000 and containing on average one referral hospital, between one and three reference health centers, and fifteen to twenty-five standard health centers. Each standard health center is staffed with at least one certified nurse and provides basic preventive and simple curative services to the five to ten villages in its area. Serious medical cases are referred upward to the health zone's reference health centers and referral hospital.

The health care system is considerably less impressive in practice, however. The relatively high physician- and paramedic-to- population ratio masks the fact that the quality of medical education has seriously deteriorated. Moreover, salaries of medical personnel are too low to permit staff the luxury of full-time attention to their professional duties. Virtually all people employed in the public sector must seek outside income in order to survive. It is not uncommon for state hospital nurses, for example, to demand private payment from a hospitalized patient or the patient's family before changing a dressing, or before administering a medication prescribed by the patient's physician. In fact, according to Janet MacGaffey, doctors, nurses, and other medical personnel routinely require payment of a personal fee before they will care for a patient. Even emergency cases are not admitted to a hospital until payment has been made.

The large number of health centers and health zones cited in statistics is similarly misleading. Many government health centers are dysfunctional, completely lacking in medications or in basic medical equipment and personnel. In the early 1990s, the publichealth system had deteriorated further as a result of civil and political unrest and severe economic disruptions. Indeed, the government's health services have in essence collapsed. What health care Zairians find comes more often private sources. The elite continue to seek quality health care abroad.

Religious organizations, notably the Roman Catholic, Protestant, and Kimbanguist churches, and international relief organizations provide the bulk of health care in Zaire, particularly in rural areas, as happened in the preindependence era as well. The Catholic medical service network is the l3f4 largest and involves primary responsibility for some ninety health zones. The Protestant network participates in the development of fifty health zones as the implementing agent of an AID-supported rural health project, it plans to develop fifty more health zones over a sevenyear period. Kimbanguist medical work centers on the rehabilitation of two urban hospitals and on management of 180 health centers scattered all over the country. Private enterprises also manage large health care facilities where they provide high-quality care. The large parastatal General Quarries and Mines (Générale des Carrières et des Mines--Gécamines), for example, owns seven hospitals and six clinics with about 2,264 beds.

Data as of December 1993