Doing good, but looking bad? Local perceptions ... - Wiley Online Library

doi:10.1111/j.0361-3666.2010.01187.x

Doing good, but looking bad? Local perceptions of two humanitarian organisations in eastern Democratic Republic of the Congo Dennis Dijkzeul Professor in Conflict and Organisation Research, Ruhr University Bochum, Germany, and Claude Iguma Wakenge Assistant Lecturer, Institut Superieur de Développement Rural, Democratic Republic of the Congo

This paper examines local perceptions of two international humanitarian organisations, the International Rescue Committee (IRC) and Malteser International, in the eastern Democratic Republic of the Congo (DRC) (formerly known as Zaire). At times, the self-perception of these organisations differs considerably from the perceptions of local beneficiaries and stakeholders. This study begins by reviewing the current status of research on local perceptions of externally-introduced humanitarian action. It goes on to discuss the local perceptions of the IRC and Malteser International, as well as the origins of these perceptions, and to show that three different narratives are used by local actors to explain their different perceptions. The paper ends with an examination of the factors that help to account for the differences in perceptions and of the implications of this type of research for humanitarian principles and management, as well as for the study of local perceptions. Keywords: Democratic Republic of the Congo (DRC), humanitarian action, humanitarian principles, International Rescue Committee (IRC), Kivu, Malteser International, perceptions

Introduction The commonplace observation that local perceptions of humanitarian action only receive scant attention is no longer correct. This paper takes stock of the existing literature on perceptions, analyses its strengths and shortcomings, and highlights the importance of research on perceptions for humanitarian action. Using as examples the medical humanitarian activities of the International Rescue Committee (IRC), a non-governmental organisation (NGO) from the United States, and Malteser Inter national, a German NGO, in eastern Democratic Republic of the Congo (DRC), this study shows how and why local Congolese perceptions of humanitarian action manifest themselves and that they can differ considerably from those of the humani tarian organisations themselves. Local perceptions of aid are in particular more diversified than most aid professionals expect. Next, this paper summarises the main factors determining local perceptions, and examines whether or to what extent the humanitarian principles of humanity, neutrality, impartiality and independence are Disasters, 2010, 34(4): 1139−1170. © 2010 The Author(s). Journal compilation © Overseas Development Institute, 2010 Published by Blackwell Publishing, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

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still salient or useful. The resulting recommendations stress the need for greater aware ness by international agencies of local perceptions and suggest ways to understand and address negative perceptions.

The relevance of perceptions in humanitarian studies Literally, perception refers to the process of acquiring, selecting, organising and interpreting sensory information (Fuchs-Heinritz et al., 1994, p. 731). In almost all research on perceptions in humanitarian action (see below), the term is used synony mously with view, and sometimes with the related terms interpretation, belief or critical opinion. The main point of perception as a concept is that it does not refer to some ‘objective reality’ but to the subjective interpretation of events, and allows for cultural and personal differences. To the extent that perceptions shape behav iour, as for example with the acceptance of humanitarian activities or principles, they can have important—sometimes unexpected—consequences. Here, the phrase ‘local perceptions’ refers to the views, beliefs and interpretations of the Congolese civilians who live in the areas where the humanitarian organisations are active and/ or located. These perceptions matter because target populations and other local stakeholders are not just passive recipients; rather, they mediate and act. Their influ ence is key to understanding the legitimacy and effectiveness of aid. At first glance, it is surprising that the study of local perceptions of humanitarian organisations has taken so long to receive regular attention, given that, as non-profit organisations, they lack the consumer feedback that sales figures and, ultimately, the bottom-line provide to commercial enterprises (Nienhaus, 1998). Lacking such a clear bottom line, it would be ideal if non-profit organisations could regularly check perceptions of their legitimacy and effectiveness. Paradoxically, many human itarian organisations are familiar with modern marketing techniques to do so, but use them far more in their fundraising and/or advocacy campaigns than in the field (cf. Dijkzeul and Moke, 2005). Schloms (2003, p. 50) and Walkup (1997, p. 51) contend that humanitarian organisa tions actually seek to discourage beneficiary feedback. According to Schloms (2003, p. 50), ‘in the first place humanitarian organisations see their responsibility as account ability to the donors’. He further argues that ‘accountability and transparency are undermined by the perception [in the eyes of the humanitarian agencies] of aid as a self-justifying cause’ (Schloms, 2003, p. 51). The traditional argument of many humanitarian organisations is that addressing urgent needs takes priority in crisis situations. In addition to these tendencies to become donor- and crisis-driven, many other factors may help to explain the traditional lack of attention to local perceptions. Language barriers, cultural differences, population movements, and difficult or dan gerous access also hamper communication with local population groups. Within the organisations, fear of large overhead costs, an action-oriented attitude, short funding cycles, a desire to hide dirty laundry, and other pressures due to working

Doing good, but looking bad?

in crises, conspire against the regular use of perception studies. A conscious or subconscious Northern ‘expert’ bias to ‘know what’s best’ may also play a role (Hanlon, 2006, p. 9). Moreover, in the past many humanitarian organisations did not see themselves as actors that would be around for a long time. Today, the idea of coming in, saving lives and leaving shortly afterwards has become a fiction in most chronic crises—for example, refugee camps exist for decades and periods of high excess mortality recur in the Great Lakes region and the Horn of Africa.1 Moreover, scholarly attention to the implementation and evaluation of humani tarian action has not kept pace with the rapid expansion of the number and roles of humanitarian organisations since the end of the Cold War in 1991. In general, most studies on humanitarian action focus on humanitarian policy and politics; imple mentation and interaction with the local populations have not been examined in equal measure. For example, Barnett (2005, p. 726) argues that ‘[m]ost research directly related to humanitarian action is produced by specialised agencies . . . [I]t is almost always directed at the policy community. Some social science research is related to humanitarian action, including the literature on humanitarian interven tion, civil wars, democracy-building, refugee studies, and peacekeeping. However, there has been remarkably little consideration of humanitarianism as an object of research’.2 In a similar vein, Goodhand (2006, p. 6) states that ‘[a]lthough a great deal has been written about political constraints, organisational questions have been a blind spot in the literature on armed conflict and intervention’. In a more gen eral fashion, Weiss and Hoffman (2007) have recently called for a humanitarian equivalent of military science to study more systematically humanitarian action and to improve learning within and among humanitarian organisations. The study of local perceptions could be a cornerstone of a better understanding of the man agement and impact of humanitarian action. Without such studies, humanitarian organisations will miss opportunities to see how their actions are interpreted and mediated at the local level, and concomitantly to improve their activities.

The perceived state of the art The number of scholarly studies that indicate the importance of understanding local perceptions, but then avoid documenting them, is large (see, for example, Bos, 2003, p. 25; Okumu, 2003, p. 129; Frangonikolopoulos, 2005, p. 62; Guttieri, 2005; Minn, 2007).3 As a result, they often indicate a particular aspect or consequence of these perceptions without substantiating or detailing them. The prevalence of this type of study may give rise to the impression that perceptions are studied infrequently. However, the body of literature on evidence of local perceptions has grown in three phases: • first, perceptions of refugees received the lion’s share of attention before the end of the Cold War, largely due to the growing number of refugee crises in the 1970s and 1980s;

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• second, with the global political changes and disappointments on the ground in the 1990s and later, the whole international humanitarian system came under scru tiny; and • third, in recent years, the study of perceptions has diversified with attention now paid to a growing array of actors and topics, partly because of the increasing avail ability of evaluation studies on the internet. Refugee perceptions One of the earliest and most comprehensive studies is Harrel Bond’s (1986) classic Imposing Aid: Emergency Assistance to Refugees. It details the creation of dependency and lack of effectiveness of aid to Ugandan refugees in southern Sudan, and explic itly takes different local perceptions into account. Harrel Bond found that the local skill sets of the Ugandan refugees, potentially lucrative or valuable for livelihood schemes, were disregarded by the United Nations High Commissioner for Refugees (UNHCR) and the outside programmes were foisted upon the Ugandans as though they were homogeneous, unskilled peasants. A 1994 evaluation of humanitarian aid in Somalia (Operations Review Unit, 1994, pp. 98–99) notes that ‘[t]he lack of a common understanding between Somalis and the international community produced a mutually unintelligible dialogue. Very distinct perceptions and respective operational norms became the context for op erating in the country’. The report discussed a ‘clash of perceptions’ in which the humanitarian organisations saw themselves as benefactors trying to help, whereas the Somalis perceived them as aggressively imposing themselves. The United Nations Research Institute for Social Development (UNRISD)’s research programme on returns of refugees has taken a predominantly anthropological approach. Allen and Morsink (1994) found that relief organisations reacted more to donor demands than either humanitarian principles or detailed knowledge of the local circumstances. For example, Rogge (1994) argues that the views of refugees on humanitarian assistance and repatriation were poorly understood. Allen and Turton (1996, p. 2) state that ‘the lack of knowledge and understanding became increasingly apparent during the 1980s’. Labels used by humanitarian organisations, such as ‘refugee’, ‘emergency’ and ‘beneficiary’, may actually say more about these bodies and their standard procedures than about the actual situation on the ground (Allen and Turton, 1996, pp. 4–9). In the aftermath of the Rwandan genocide of 1994, Pottier (1996a, p. 403), another anthropologist, remarked that the ‘refugees’ views . . . remain poorly understood’. Nevertheless, he derived his data from his work for the Joint Evaluation of Emergency Assistance to Rwanda (Study III team), which took refugee perceptions seriously. In his follow-up articles, Pottier (1996a; 1996b) mentions shortcomings in the ex ecution of refugee programmes, due to their failure to understand the diversity of refugee groups—in particular génocidaires versus bona fide refugees. He further noticed that UNHCR and international NGOs often failed to understand the ‘dynam ics of political life in the camps’ and the political complexities in the Great Lakes


region. Consequently, they failed to build on local community initiatives, provided culturally inappropriate food aid, complicated repatriation, and did not comprehend how and to what extent their activities were appreciated. Turner (1998, 2004), also an anthropologist, analysed the role of rumours in the lives of Hutu refugees who fled Burundi to camps in Tanzania. He found that ‘[l]iving in uncertainty, having their symbolic order crumble due to violence and flight, they attempted to create some sort of order through rumours, and . . . many of these rumours circle around global issues’ (Turner, 2004, p. 237). Examples include the supposed role of the US in influencing the political situation of the Great Lakes. It goes without saying that a mutually reinforcing relationship between perceptions and rumours can exist in order to make sense of life in times of upheaval. Among recent publications, Bakewell (2000) evaluated how Angolan refugees in Zambia had self-settled so that it became ‘practically impossible to distinguish be tween refugees and hosts over time’. He warned that ‘[n]eglecting the life and world of local people will make it impossible to understand the process by which external interventions are mediated at the local level to give particular outcomes, and valuable lessons which could help alleviate suffering will be lost’ (Bakewell, 2000, p. 103). Sperl (2002) examined the experiences of Malian refugees from Algerian and Mauritanian camps of repatriation and rebuilding. The more (community-based) initiatives they could engage in, the more positive they felt about the assistance they received. Furthermore, Rutta et al. (2005) studied Burundian and Rwandan refugees’ perceptions of healthcare quality 4 in camps in Tanzania, and noted the importance refugees attached to issues that indirectly affected health, such as ‘secu rity (for instance, repatriation, general camp security, rape) and lack of non-food items (for example, plastic sheeting, clothes, blankets and cooking utensils)’ (Rutta et al., 2005, p. 305).5 The whole humanitarian system After the disappointments in Yugoslavia (1991–99), Somalia (1993) and Rwanda (1994), another concern grew within humanitarian circles: ‘There is a perception that the agenda has shifted from a debate regarding how to reform the humanitarian sys tem, to the question of whether it is worthy of reform at all’ (Macrae, 1998, p. 24). Put differently, this type of perception did not only pertain to local views of field operations, but also focused on the whole humanitarian enterprise. Initially, concern grew within humanitarian organisations about donor govern ments that promoted aid for their own political purposes or criticised the lack of effectiveness of aid in order to cut back on funding. Later, concerns continued to rise when military contingents dominated or sidelined humanitarian organisations (such as in Kosovo), and when humanitarian arguments were used to justify war (Slim, 2003). With large-scale aid programmes in Afghanistan and Iraq, this concern trans formed further into a debate on whether Western humanitarianism was still being perceived as universal or as a form of Western imposition (Donini, Minear and Walker,

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2004). Increasingly, attention shifted to the political interests behind (non-)action and the perceptions thereof. In particular, a controversial debate has arisen on the roles and perceptions of Western NGOs active in predominantly Islamic countries. Are Western humanitarian organisations seen as ‘missionaries and spies’? (Osman, 2006). If so, then not only humanitarian principles, access and effectiveness are at stake, but also staff security (Slim, 2004). The Feinstein International Center combined attention to issues affecting the whole humanitarian system with the study of local perceptions through interviews and focus groups. Its first study centred on mapping the security environment, which incorporated the different views of local communities, staff members of peace support operations and assistance agencies (Donini et al., 2005). The second focused on the challenges of universality, terrorism, coherence and security (Donini 2007; Donini et al., 2006, 2008). It was based on extensive in-country case studies. For instance, Mowjee (2007) wrote a case study on the DRC, which mainly became an evaluation of the integrated nature of the United Nations Organization Mission in DR Congo (MONUC). However, the study was stronger in explaining humani tarian organisations’ perceptions of MONUC than those held by local Congolese. Diversified perceptions Scientific interest in local perceptions has grown and diversified rapidly in recent years. Harragin and Chol (1998) carried out an anthropological evaluation of food aid to (subgroups of ) one ethnic group: the Dinka in southern Sudan. They noted that aid agencies define vulnerability according to socioeconomic criteria, whereas the Dinka do this in terms of kinship, in particular the absence of a large immediate family. Contrary to the aid organisation’s intentions, most Dinka quickly redistrib uted the aid they received within their extended families. Harragin and Chol (1998, p. 26) also noted that aid workers ‘are seen by some as using the plight of the people in Sudan to raise money to keep them in a job’.6 The Henry Dunant Centre for Humanitarian Dialogue (2003) conducted research on the views of paramilitary forces in Colombia and Islamic opposition movements in Central Asia. Other scholars also honed in on fresh topics: Savage et al. (2007), for example, studied perceptions of corruption in humanitarian assistance in Liberia. In the meantime, Richards (2005) continued the anthropological tradition of de tailed fieldwork, but the authors in his edited volume focus not only on refugees, but also on other groups in conflicts, such as militia members, demobilised youth, public officials and agriculturalists.7 Attention to local perceptions in natural disasters also grew. The Disasters Emer gency Committee (DEC)’s evaluation of the 2001 earthquake in the Indian state of Gujarat used several qualitative participatory data-collection methods to assess the perceptions of affected communities. In its final report, it innovatively applied the principles of the 1994 Code of Conduct for the International Red Cross and Red Crescent Movement and Non-Governmental Organizations (NGOs) in Disaster Relief as evaluation benchmarks (Humanitarian Initiatives, Disaster Mitigation Institute and Mango,


UK, 2001). The Fritz Institute 8 has also published the results of surveys after, for example, the Indian Ocean tsunami of 2004, the Pakistani earthquake of 2005 and Hurricane Katrina of 2005. Its reports invariably stress that local voices are insuf ficiently heard, that aid should concentrate more on strengthening local capacities, and that frequently various needs remain unmet. Finally, information on perceptions can be found in the parallel literature on local participation. Although participatory methods evolved primarily in development studies, participation has received increasing attention in humanitarian action (see the Active Learning Network for Accountability and Performance in Humanitarian Action (ALNAP)’s Global Study on Consultation and Participation of Disaster-affected Populations 9 and various studies by the Feinstein International Center 10 ) and standards (such as through the Code of Conduct and the Sphere Standards 11). It is tempting to see participation of local population groups as a way to contribute to more positive per ceptions. After all, ‘local populations are unlikely to feel a personal attachment to a solution externally imposed unless actively consulted or involved in the interven tion strategy’ (Gizelis and Kosek, 2005, p. 363). Nevertheless, if participation is construed narrowly as (joint) activities with the beneficiaries, it may obstruct atten tion to perceptions of other stakeholders, such as local government officials and civil society representatives, which can also deeply influence these activities. Moreover, participation has also been used as a rhetorical management device and a guise for acquiring free labour (de Waal, 1997, pp. 55–56, 143; Uvin, 1998, pp. 130–140), which can colour local perceptions very negatively. But if participatory approaches succeed in including the perspectives of both target groups and other stakeholders, they may provide important insights into local perceptions.12 Still, participation is just one factor among many (for instance, local gender norms or the economic situ ation) that can influence perceptions. Analysis Together these studies show that the study of perceptions has broadened from mainly anthropological refugee studies to the inclusion of other groups in conflict zones, as well as the humanitarian system as a whole, while combining different methodo logical approaches.13 All studies confirm that the way in which humanitarians or outsiders in general are perceived can differ considerably from the way they see them selves. In addition, different perceptions may co-exist among various population groups. The studies also frequently indicate that humanitarian organisations miss (some) opportunities to engage local actors, to build on local capacities, and to under stand broader political dynamics, including resistance and hostility. These studies, however, say surprisingly little about the degree to which nega tive perceptions are inevitable in an insecure environment, where aid workers with finite resources introduce outside perspectives on what is most needed, such as measles immunisation, micronutrients, and gender equality, which can be at odds with the priorities of local leaders and beneficiaries. For instance, doctors from med ical humanitarian organisations regularly confront local beliefs about healthcare that

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are unscientific and perhaps even dangerous. Similarly, food aid is not selected entirely for its local appropriateness, nor is hospital food given to maximise the enjoyment of patients. In those cases, it becomes the professional responsibility of aid workers to explain their choices and sometimes dispute or disregard local be liefs, priorities and related perceptions.14 In this respect, some perceptions matter more than others. Most people are open to professional explanations regarding medical or nutritional priorities, but percep tions that the organisations have a political agenda or are corrupt can be far more difficult to address. At times, there is only a thin line between the professional con cerns and more political issues, for example with regard to gender in Afghanistan. Humanitarian organisations thus need to develop a typology, or at least a priority list, of perceptions to be able to focus on those perceptions that affect their core objec tives of saving lives and preserving dignity. One of the most important outcomes of taking local context and political dynamics into account may be understanding the degree to which a humanitarian organisation is perceived as an actor with (hidden) political or economic aims. If this occurs, the organisation itself would be seen as contravening the traditional humanitarian principles of humanity, neutrality, impar tiality and independence, thereby compromising its legitimacy and effectiveness. Further analysis also shows that, while attention to local perceptions of human itarian action has been increasing, it has not been systematic enough. With the ex ception of research on refugees, these studies rarely refer to each other. Cumulative learning has therefore hardly occurred. Most studies, moreover, concentrate on ‘humanitarian action’ in general without identifying why and how different local population groups view specific humanitarian actors or actions. Is this too difficult methodologically or do researchers fear that they cannot gain access to humanitarian organisations if they are too critical? Without such studies, however, humanitarian organisations lose opportunities to improve their effectiveness. Finally, research on perceptions could still use more methodological rigor. Obviously such research is frequently done in the most difficult circumstances in which a strict protocol is often nearly impossible to follow. This is one of the reasons why the body of literature on this subject remained scant for such a long time.15 The main methodological problem is to reflect the diversity of population groups. Consequently, for field researchers the question becomes how to situate respondents (Pottier, 1996b). In particular, anthropological scholars have carried out extensive field studies, based on participant observation, and/or in-depth interviews and focus groups to get to know the diverse population groups really well.16 The strength of such ‘qualitative research lies in validity (closeness to truth) . . . The soundness of qualitative meth ods is greatly improved by using a combination of research methods – a process known as triangulation – and through independent analysis of the data by more than one researcher’ (Rutta et al., 2005, p. 292). Nevertheless, even when validity is assured, it is not certain that reliability, or at least replicability, is present in most current perception studies.17 In sum, perceptions matter to humanitarian organisations in terms of their legiti macy (doing the right thing), effectiveness (doing things right) and security (doing


things safely). This research set out to combine qualitative and some quantitative research, mainly through field visits and questionnaires, on the IRC and Malteser International and the degree to which they were seen by local population groups to have a political or economic agenda. Our research focuses in particular on the health activities of both organisations, since these are more traditionally humanitarian than work in such fields as capacity building and food security, which is more developmental.

The situation in the DRC Despite the presence of a UN peacekeeping force (MONUC) since 1999, the re unification of the DRC in 2003, and elections in 2006, several parts of the country still suffer from regular armed violence and conflicts involving several armed groups and the undisciplined national army (Turner, 2007; ICG, 2007). Due to decades of neglect and the ongoing security crises, the health situation in eastern DRC is char acterised by a weakened health system with little or no central state support and high excess mortality (Roberts and Despines, 1999; Coghlan, Brennan and Ngoy, 2006; Coghlan et al., 2008). Since the official peace accords in 2003, more than two million people have died due to the crises, mainly of malnutrition and diseases that were not prevented because of the breakdown of economic and social structures (Autesserre, 2008). To a large extent, however, a decentralised structure of health zones has been pre served throughout the crises. Each health zone normally has one central hospital, one or two reference health centres, and several regular health centres with a nurse and a few support staff. In each province, the provincial health inspection office officially supervises its health zones. This office is led by a provincial health inspec tor, who is responsible for the overall health policy in the province and determines the fee structure. Each health zone is managed and supervised by a chief medical officer (CMO), who is responsible for monitoring the daily activities of all health facilities in a health zone and ensuring the quality of services provided to patients. CMOs and their support staff work from the health zone office, which is generally located at the central hospital.18 The support of humanitarian organisations was nec essary to maintain and upgrade the poor health services.

Research design We decided to carry out this research because we knew from earlier experiences that local Congolese perceptions of humanitarian action were sometimes negative with regard to its effectiveness and political motivations. For example, both the IRC and Malteser International sometimes face rumours about their supposed links to armed factions. In Bukavu, the capital of South Kivu province, some Con golese almost automatically assume that the IRC, as a US organisation, is biased towards the political aims of the Rwandan government. The reasoning behind this rumour seems to be that the administration of former US President Bill Clinton

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supported the Tutsi-based regime of President Paul Kagame in Rwanda, which in turn supported the main rebel group(s) in eastern DRC. In a somewhat similar vein, Malteser International works in an area where the Democratic Forces for the Libera tion of Rwanda (FDLR)—better known as the Interahamwe, Rwandan genocidaires, who have fled into the Congolese rainforest and prey on the local population—is active. As a consequence, local rumours suggest that Malteser International is close to the FDLR. Other perceptions concern the powerful position of international organi sations vis-à-vis local ones. However, no information exists as to how widespread such perceptions are and where and how exactly they originate or are maintained. Of course, both organisations will reply that they are following the humanitarian imperative: trying to help people who are most in need, wherever they may be found, and that their aims are not to take political sides or to solve the conflict itself. Organisations We selected the IRC and Malteser International because they are well-established international humanitarian organisations with considerable experience of severe humanitarian crises, including in the DRC. Both provided relief during and after the Rwandan refugee crisis, and over time extended health support to the popula tion of eastern DRC. Although the two organisations also carry out other activities, for example con cerning gender-based violence, nutrition and food security, Malteser International is more traditionally humanitarian. The IRC has been changing its approach from more humanitarian to broader developmental activities in the DRC since 2001.19 At the time of this research (July 2007), both organisations had instituted cost-recovery systems, in which they provided medical supplies for free, but the patients paid a fee for the health services rendered at the local health facility. The collected revenues were then used for staff incentives, operating and maintenance costs, and sometimes as savings (Dijkzeul and Lynch, 2006a, 2006b). Both organisations supplied us with information on the health centres they were supporting or had supported, and we were able to present their Congolese health staff with semi-structured questionnaires. In all other respects, we operated inde pendently of both organisations.20 Development of questionnaires Perceptions can partly be recorded through quantitative methods, but most studies discussed above recorded them using qualitative methods. We developed three semistructured questionnaires for three categories of local participants in order to garner qualitative and quantitative information on four groups: 21 • Local health supervisory staff of the IRC and Malteser International. • Beneficiary population, which was subdivided into patients, health committee mem bers, and people who were not using health services (non-patients). Depending on availability, they were interviewed either alone or in focus groups.


• Local authorities (church, administration and traditional leaders, as well as civil society organisations). • Local health system staff (at the provincial level, at the zone level and within health facilities). Sites and sampling The difficult security and transport situation made the use of probability sampling impractical, as we could not reach all of the selected facilities and populations (see below). Instead, we used two-stage purposive sampling. First, we selected six health zones that reflected the geographical, cultural and ethnic diversity of the popula tion served by each of the two NGOs. The Nyantende, Walungu, Kaniola, Kabare health zones are predominantly Bashi, the Kalehe zone is traditionally Bahavu, and in the Mwenga zone the Barega dominate. The health zones also reflected different degrees of insecurity, which impacts considerably on health-seeking behaviour. All zones faced regular violence, but Nyantende was relatively safe; whereas Kaniola and Mwenga were unsafe with armed bandits and militia staying in the forest close by. The other zones fell somewhere in between. In addition, the geographical diversity allowed us to study local perceptions both during the period of operational support in five zones and after the cessation of operational support in two zones. The IRC had already withdrawn (in 2006) from northern Mwenga, while Malteser Interna tional was still active in the southern part of this zone. Malteser International withdrew from Nyantende in July 2007. At the time, Malteser International was also preparing to leave Walungu and Mwenga as the economic indicators had been improving. Hence, the IRC was or had been active in the Kabare, Kalehe and (north ern) Mwenga zones, and Malteser International in Nyantende, Walungu, Kaniola, and (southern) Mwenga. The research started in Bukavu, where both organisations have their local head quarters, but do not support health facilities directly. First, we interviewed the provincial level authorities—at the governor’s office and the provincial health inspec tion office, who provided us with an official letter to obtain access to the health facilities. In each health zone we visited the central health office and then the staff of the other health facilities. We selected one health centre as far away as possible from our sleeping address, so that we could cover the largest geographical distance possible. With this facility as our starting point we continued to the other centres. In the field, we could visit on average three to four health facilities, as well as one local authority, a day. At a health centre, we would look for the head nurse; if she/ he was not there, we would look for other health staff. We would ask whether the health committee members were available for interview and/or we would pose our questions to a group of patients (if present).22 When possible we also interviewed non-patient groups away from the health centre, for example at a market place or manioc mill, to see whether and how their opinions differed from patients and health committee members. At the end of our research, we continued with interviews at the local headquarters of the medical and non-medical civil society organisations in Bukavu (see Table 1).

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Table 1 Respondents Respondents

Malteser International Focus group

Interview

IRC

Focus group

Interview

Both organisations

Focus group

Individual interview

NGO staff Congolese health supervisory staff of each NGO

Total number of people interviewed

14 0

8

0

6

N/A

N/A

Beneficiary population

14

202

Patients

8

2

12

0

N/A

N/A

121

Local health committee members

2

4

6

5

N/A

N/A

31

Non-patients

4

0

3

0

N/A

N/A

50

Local health system staff

65

Provincial health inspection

N/A

N/A

N/A

N/A

0

2

2

Health zone office

0

5

2

1

0

3

15

Health facility staff

1

14

9

8

N/A

NA

48

Local authorities

35

Church officials

0

1

0

3

0

1

5

Local government officials

0

0

0

2

0

1

3

Traditional leaders

1

5

0

5

0

0

18

Local civil society organisation staff

N/A

N/A

N/A

N/A

3

3

9

TOTAL

16

39

32

30

3

10

316

Timing of the assessment Field research was conducted in July 2007 in South Kivu province, when it seemed that this part of the DRC could slowly, albeit haltingly, shift from an acute humani tarian crisis to a more stable development situation. Nevertheless, violence persisted, and some areas, such as Shabunda, did not receive sufficient humanitarian assist ance. The situation in North Kivu, close to the research area, was even worse with the rebellion of General Laurent Nkunda.23 Constraints The reliability and validity of the data was also influenced by several constraints and methodological issues. At times, insecurity influenced our means of transportation


as well as the quality of some interviews. At night we would stay as guests of local priests as this offered a measure of security. Some health zones can only be reached by aeroplane or boat, but we did not have the financial resources for these types of transport. In general, the further away from Bukavu, the more difficult transport was (bad roads) and the higher the level of insecurity. Even in the safest zone, Nyantende, we visited a health centre that had been looted the night before. Some zones, such as Kaniola and Mwenga, still face regular violence by armed militia. In two patient focus groups in these zones we noticed that our interviewees were severely traumatised, which made for difficult interviewing as these patients could not con centrate well and remained suspicious of our intentions. We also had to cut short several field visits due to localised violence and to help with transporting patients.24 Most patients arrive early in the morning at the health centres. If we visited a health centre later in the afternoon, sometimes there were no patients left or there were only lactating mothers with newborn children staying for observation or addi tional nutrition. Thus, breastfeeding mothers were overrepresented in our patient focus groups. In general, the more rural (and remote) the health centre, the fewer patients, non-patient groups, and health committee members we were able to interview.25 Finally, there is an important cultural aspect to our data collection. Many Con golese participate eagerly in group conversations, but feel less at ease with being singled out for individual interviews. Consequently, we allowed many focus groups to form spontaneously (in particular with local health facility staff, patients and non-patient groups). Mugiraneza and Levy (2003, p. 111) argue in a similar vein: ‘Humanitarian aid agencies should not hesitate to adopt traditional forms of dialogue and participation’. Data quality and analysis The main thrust of this research was qualitative because we chose purposive sam pling and carried out many focus group interviews. Nevertheless, we used semistructured questionnaires, so that we could cross-tabulate most data and determine frequencies. This facilitated breaking down the data for analysis by health zone, by humanitarian organisation, and for different population groups and local authorities (see Table 1). In this way, it was possible to identify trends in our data. Given the insecurity and limited resources, this helped to strike a balance between validity (which we consider high) and reliability (which we consider better than most per ception studies, because in principle this study is replicable and the quantitative data can be double-checked). However, purposive sampling and focus groups cannot ensure that all participants surveyed receive equal weight. Hence, the main shortcoming of our quantitative analysis is that it aggregates focus group and individual questionnaire results. More random sampling and individual interviews would have facilitated generalisation of the research results. However, the additional costs of such an approach together with challenges posed by ‘traditional forms of dialogue’, insecurity and transport, were prohibitive.

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Dissemination of findings After we had analysed our data, we sent the text (but not the research data, as we had promised respondent confidentiality) to both organisations and asked for their comments. Malteser International’s management replied that, due to this research, they strongly felt that they had to communicate even more with the local popula tion and authorities. The IRC stated that it more or less expected these results and asked whether we could stress that this research was carried out independently and indicate clearly why some rumours could not be verified in order not to give too much substance to them. The IRC also asked us to include a literature reference on its position on cost-recovery (see endnote 28).

Main findings The questionnaires were divided into three sections: 1) the general situation; 2) interaction of the organisation(s) with the beneficiary population, local health staff and authorities; and 3) humanitarian principles versus political and economic inten tions. The questionnaires ended with open questions about the trends in judgment about both organisations during the last two years. At the end of the interview, we also asked respondents whether they still had anything else they wanted to say; the ensuing discussions greatly facilitated our analysis. We will first consider the outcomes of the questionnaire presented to Congolese staff members of the IRC and Malteser International. The outcomes of the other two questionnaires have been divided into a quantitative and qualitative part. The quantitative data show what the perceptions are, while the qualitative data provide the building blocks to explain how these perceptions came about. The perceptions of local staff members of both organisations We interviewed local Congolese staff members of both organisations, who monitored as health supervisors the local health facilities that receive support. At the IRC we inter viewed six out of a total of 10 supervisors and at Malteser eight out of 11 supervisors.

General situation In both organisations the staff members indicated that the overall security situation had either slightly improved over the past two years, or had stayed more or less at the same low level. They also noted that it was important to have good relation ships with the local population in order to enhance their own security in the field, and underscored the importance of effective communication with the beneficiaries, local authorities and health committees in this respect.

Interaction with the local population The staff members of the IRC and Malteser International were generally proud of their own organisation and their work. In both organisations, local staff considered


their own organisation better than most other international actors in eastern DRC. And they stressed how important it was to them to help the local population. At times, they worried about the constraints generated by donor governments. For example, late, irregular or low levels of funding create problems with maintaining the humanitarian principles, selecting local partners, advocacy, planning and budg eting. This, they felt, may also result in negative local perceptions. They also rec ognised practical problems in execution and communication. In particular, they mentioned some internal management problems, such as the relatively low quality of some expatriates and, in the case of the IRC, delays with international drug orders. Almost all staff members said that the local authorities viewed their organisation as a true partner and to a far lesser extent as a funding organisation or a source of employment. None of the supervisors at either the IRC or Malteser International saw their organisation as a competitor of local government.

Politics and principles Surprisingly, one-half of Malteser International supervisors said that their organi sation had ‘limited hidden intentions’; only one IRC staff member mentioned this. This seems to be due to the fact that Malteser pays relatively low wages and staff would like to earn more. Only one IRC staff member referred to the fact that the IRC is a US organisation as a cause of negative local perceptions. Three others said that the population believes that the international NGOs are ‘politicised’, but they felt that the IRC was actually apolitical. To demonstrate its neutrality, one IRC staff member proposed that the IRC should work simultaneously in two new health zones: one that had been ‘controlled by Rwandan-supported rebels for a long time, whereas the other was well known for its popular resistance against these rebels’. In both organisations, staff mentioned that the local population was only moderately or not at all familiar with the traditional humanitarian principles of humanity, neu trality, impartiality and independence, and that they knew these principles better. The supervisors also wanted their respective organisations to expand into other health zones, given the suffering that they regularly observed. IRC staff actually appreciated that their work focused increasingly on long-term sustainability. Two Malteser International staff members flagged their interest in more developmental work too. Given the high level of unmet needs of the local population, the staff members did not perceive a tension between humanitarian and more developmental work. All in all, a picture emerges of Congolese staff members feeling generally confident that they can improve their work over time and that its effectiveness and legitimacy are high, while also noting several execution and communication problems. The perceptions of the beneficiary population, health system staff and local authorities: quantitative analysis

General situation In all zones, almost all respondents indicated that security had improved, but added in the same breath that it had done so at a very low level. Obviously, it remained a

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large problem that the population, to some extent, had become accustomed to. A few people redefined it as a problem of injustice. Drought and water problems were also highlighted, especially in the Kalehe health zone. High health costs were cited as a problem by 80 per cent of the beneficiary population in Malteser International areas, but only by 20 per cent in IRC areas. The most mentioned problem, however, was food insecurity and malnutrition, noted in 70 and 68 per cent of beneficiary population interviews in Malteser International and IRC areas, respectively.

Interaction with the local population All members of the beneficiary population we interviewed confirmed that they or their families had received assistance from the organisation active in their respective health zones.26 This was also true for the non-patient interviews held away from the health centres. Hence, the whole population was aware of the medical activities of humanitarian organisations. Almost one-third of the beneficiary interviews also commented on their nutrition activities. Food security activities, however, were only alluded to in five (Malteser International) and 16 per cent (IRC) of the interviews with the beneficiary population.27 When asked whether they had been informed of the aid they were going to re ceive, one-quarter of Malteser International beneficiaries said that they had been informed. When asked whether their opinion about which aid they preferred had been sought, once again one-quarter of Malteser International beneficiaries re sponded positively. Eighty per cent of IRC beneficiaries stated that they had been informed (100 per cent in the case of the health committees). In comparison, 44 per cent indicated that their opinion on preferred aid had been solicited. The beneficiary population judged the impact of the aid it received very positively. All beneficiaries in the Malteser International zones replied that their personal experience of received aid was positive. For the IRC, 92 per cent replied positively. The beneficiary population also remarked that the aid went to the people who needed it most (Malteser International 90 per cent; the IRC 92 per cent), which is in sharp contrast to regular complaints about corruption in food aid. In addition, all people interviewed in Malteser International zones said that the organisation was respectful, whereas in IRC zones a solid 88 per cent found the organisation to be so. In the qualitative interviews (see below), however, we found that local people tend to make a distinction between the organisation and its local staff. They can be highly critical of the organisation’s staff members, but remain positive about the organisation. Hence, for Malteser International, 90 per cent of the population stated that the organisation had come to the DRC because it wanted to help, while 92 per cent of the population interviewed in IRC zones said the same. The remaining few answers were more critical of staff members of both organisations: notably that they had come to get rich. All in all, this data on interaction clearly show how much the beneficiary popula tion appreciates that its medical needs are being addressed. This helps explain why impartiality never played a large role in discussions with the beneficiary population.


Politics and principles We did not immediately enquire about the four traditional humanitarian principles, but instead asked the beneficiary population (health committee members, patients and non-patients) whether they thought that the organisations had hidden political or economic intentions or aims. Sixty-five per cent of the beneficiary population stated that Malteser International did not have any hidden goals, five per cent said that it had such goals in a limited way, and 30 per cent were not sure whether this was the case. For the IRC these values were 88, four, and eight per cent, respectively. None of the patients interviewed in the IRC-supported zones said that the organisa tion had political or other aims. When we asked the local health staff at the health facilities and health zone offices the same questions about the possibility of hidden objectives, the percentages who thought that there were no hidden aims went up to 77 per cent for Malteser Inter national (nine per cent thought it had limited hidden intentions and 14 per cent were not sure), but down to 32 per cent for the IRC (32 per cent said that it only had hidden intentions in a limited way, five per cent said that it had hidden intentions, and another 32 per cent did not know whether this was the case). In Bukavu, the answers by civil society organisations to the question of hidden intentions differed considerably: 60 per cent stated that the IRC had hidden inten tions and 40 per cent said that it did not. Thirty-three per cent of the health organi sations in Bukavu said that the IRC had hidden intentions; another 33 per cent said that it had hidden intentions but only in a limited way; and 33 per cent did not know, but when probed, most of these respondents indicated that they had tried to be diplomatic about the IRC or had heard rumours that they could not confirm. In general, the closer we held interviews to Bukavu, the more negative opinions we heard about the IRC. Non-medical civil society organisations and local authorities were the most critical, but, as indicated, even health organisations were more crit ical than patients. One should also note that some interviewees declined to answer this question, because they felt uncomfortable with it (once again this happened more often the closer we got to Bukavu). As for Malteser International, the picture was different, with most negative opinions related to its activities in Nindja (see below). In general, the beneficiary population thought that both organisations succeeded well in remaining neutral with regard to the armed conflict and inter-group ten sions (95 per cent said so of Malteser International and 83 per cent of the IRC; the rest did not know). Ninety-five per cent said that Malteser International could deal best with insecurity by remaining independent, while 56 per cent said the same for the IRC—the other respondents were not sure about the best course of action. Similarly, 100 per cent of the population said that Malteser International operated independently outside any larger integrated programmes. For the IRC, the percent age was 68, and 32 per cent did not know. Ninety per cent of the beneficiary population thought that the insecurity did not have much of an effect on the functioning of Malteser International, and 10 per cent did not know. For the IRC, 64 per cent said the same, and 32 per cent did not know.

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We also asked whether the organisations, in the eyes of local authorities and health staff, had played a role in the peace process. Thirty-two per cent said that the humani tarian organisations did not play a role in the peace process: ‘they are neutral’. 57.3 per cent applied a broader interpretation of peace and said that good health was an important contribution to peace. The remaining 10.7 per cent said that they did not know. In other words, without using the terms, the respondents’ definition of peace as either negative (absence of violence) or positive (peaceful development) also deter mines the perception of humanitarian action. Finally, we asked two questions about changes in perceptions of the recipient popu lation since the organisations started working in their health zone. In this period, the beneficiary population’s opinions of both organisations deteriorated somewhat from very good to good (Malteser International: 95 to 80 per cent; and the IRC: 96 to 68 per cent). The perceptions of the beneficiary population, health system staff, and local authorities: qualitative analysis To identify the reasons for trends and differences in perceptions, we relied heavily on our qualitative data. While analysing this data, no differences were observed about the general situation and security, but many details on the interaction of both organisations with the beneficiary population, staff members of the local health sys tem, and local authorities were added. These also have important implications for the application of the traditional humanitarian principles.

Arrival One of the main stories told in and around Bukavu concerned the time of entry of the IRC. It is frequently recounted that it arrived in 1996 together with the Rwandan forces that supported the Alliance of Democratic Forces for the Liberation of CongoZaire (AFDL) (Laurent Kabila’s army). At the time, the IRC actually operated a pro gramme for returning Rwandan refugees and later on helped the local population with primary healthcare activities.

Local politics and principles The Rwandan-supported rebels imposed staff members on the humanitarian organi sations and controlled the local administration, including the health institutions— this also affected the IRC and Malteser International. Especially within civil society organisations this is seen as proof that the IRC cooperated with the rebel govern ment. Further remarks included: ‘The head of the IRC was close to the Rwandan health inspector’; and ‘He was wearing army clothes at the time’. That other organi sations, including Malteser International, had to deal with a similar situation received less attention, as the Rwanda–US connection is an article of faith in eastern DRC. A somewhat comparable problem arose for Malteser International in Kaniola, where it had to pass through the rainforest controlled by the FDLR to reach a health centre


in Nindja. This caused distrust of Malteser International in the population on the other side of the forest, because it assumed that the organisation was close to the FDLR. A local supervisor from the health zone office, however, said that he had negotiated with the FDLR to ensure access by Malteser International. Another problem arose in Mwenga with local IRC health supervisors. They all came from Bukavu and did not belong to the local Barega ethnic group. The Barega did not fully trust IRC staff and occasionally accused them of following their selfinterests. Such ethnically-based animosity is part and parcel of the perceptions of humanitarian action in eastern DRC. The local authorities and health staff in the health zones and Bukavu were queried about whether the local population understood the four traditional humanitarian principles. The tenor of the responses was that the principles of both organisations were often moderately or badly understood, which sometimes led to difficulties in the field, mainly in the form of false expectations about the roles and capabilities of the organisations.

Execution and trust The other problems involved the population and health staff at the facilities, as well as the supervisory staff at the zone’s health bureau, and the execution of aid. One prob lem pertained to logistics: many people and local authorities mentioned ‘Operation Retour’. According to them, staff of both organisations delivered drugs and other medical supplies and then later took them back in their white cars. They felt that this was either organisational incompetence or staff acting corruptly on their own. They would, for example, rhetorically ask: ‘why are those cars moving with only a few boxes of medicine?’ This perception was widespread; the term ‘Operation Retour’ was used in all health zones. Staff members of both the IRC and Malteser Interna tional acknowledged that logistics should be strengthened in their organisations. A similar problem centred on understanding of the security situation. Some people wondered how it was possible that, sometimes, the organisations would leave in their white cars just before insecurity emerged. ‘If the organisations are apolitical, how do they know when insecurity comes?’ In other words, the organisations were not perceived as influenced by insecurity, but there were rumours on how they influenced insecurity. Unfortunately it is common for armed militia to loot health centres the night after a drug delivery. Yet another problem, not expected in our questionnaires, concerned Kanyonya, a vampire myth. In one part of the Mwenga health zone the rumour circulated that IRC cars transported vampires at night. The zone’s CMO indeed explained that he had to battle this rumour repeatedly. This represented a novel challenge to the humani tarian principles, which were not formulated to confront the supernatural. Underneath the three preceding issues is local wonderment over the means of trans portation of the organisations. Local authorities and other people rarely have access to cars, but would also like to benefit from such transport. They perceive cars as symbols of wealth and power, and are puzzled about their costs and the way they are being used.

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Another crucial issue in the IRC zones was irregularity of supplies. Patients would visit the health facilities less often or not at all if drugs and other supplies were not available. Therefore, such stock supply depletions also disrupted the cost-recovery system through foregone revenue (implying that health facility staff members earned less money). This recurring problem bothered health staff even more than the patients because they dealt with it on a daily basis and bore the financial consequences. Some health facility staff stated that they had not received sufficient stocks in three months. This was one of the main reasons why they thought that the IRC had hidden intentions. Together with ‘Operation Retour’, insufficient stock supplies contrib uted to fears and suspicions of corruption. Closer to Bukavu, this also became linked with critical stories about the IRC as a US organisation. IRC staff did explain that there had been severe delays with international orders of drugs and other supplies. In this respect, the issue of cost recovery also became controversial. With regard to the foregone revenue due to stock supply depletions, health centre staff noted ‘that the IRC is good for the population, but less for the health staff ’. In Malteser International zones, the incentives paid to health staff had been declining since the introduction of a performance measurement system, which caused similar dissatis faction. Yet these zones did not suffer from stock supply depletion as most drugs and medical supplies are ordered locally. Simultaneously, staff in the IRC-supported zones, Kabare and Kalehe, discussed their discomfort with the proposed free healthcare in the near future, as proposed by the United Kingdom’s Department for Interna tional Development (DFID). They feared a lack of sustainability: ‘What will happen when the donor stops funding?’ and ‘how will the population react then?’ They feared that free healthcare could actually disrupt the whole health system.28 The beneficiary population also considered it very important that the local health supervisors of both organisations talked to people who were ill. This was repeat edly highlighted as a sign of respect and professionalism; beneficiaries appreciated both personal attention and more explanation concerning the functioning and pri orities of the two organisations. Similarly, staff at the health centres as well as local authorities could complain bitterly that they were not involved or consulted regu larly by both organisations about their plans and activities: ‘They only talk with the health zone or provincial health inspection staff ’. For civil society organisations and other local authorities in and around Bukavu this issue was even more pressing; they argued that humanitarian aid addressed the effects of the conflicts and not the causes. They would have preferred that the large sums of money spent on human itarian action over the years had been invested in peace-making: ‘Because only peace really improves the humanitarian situation’. They felt frustrated that they were not consulted on the overall direction that international aid should take. In other words, they did not feel that their needs had been taken into account. In general, health zone supervisory staff members were generally more nuanced in their opinions of both organisations than personnel at the health facilities or local authorities, because they had worked with one of the humanitarian NGOs in signing the health memorandums of understanding (protocol d’accord) and interacted more


frequently with NGO staff. As a result, they understood the principles, objectives and working methods, as well as the constraints of the humanitarian organisations better. Finally, local health facility staff reacted negatively when either the IRC or Malteser International would leave the health zone. This was seen as a breach of trust. In Mwenga, the IRC was perceived as an organisation that had not kept its promises. Nevertheless, health facility staff and the local population deeply regretted that the IRC had left. We also studied the Nyantende zone on the day that Malteser Inter national was departing and handing over its tasks to Louvain Developpement, a Belgian development NGO. Staff members at the health centres were very apprehen sive, sometimes even angry. At that moment, they preferred Malteser International to stay, including its performance-based health supervision, which is surprising in light of their comments about declining income. Although this topic requires fur ther research, it indicates that local exit and hand-over strategies need to be managed carefully. When local partners and populations perceive such a departure as a sudden move, disappointment and stories of broken promises will linger. In general, steps towards more developmental work, such as the cost-recovery system and a hand-over, easily cause apprehension and dissatisfaction among health centre staff. In and of itself, the perceptions discussed above are not substantiated facts that prove or disprove the possibility of hidden political or economic intentions by either the organisations or their staff members. They do show, however, that such nega tive perceptions inevitably arise—and exert influence—when an organisation has to ensure access by interacting with forces in control of roads and government institu tions, and when an organisation provides aid in a situation of ethnic distrust, or when there are problems with communication and implementation. The organisation can then lose its perceived neutrality.

A tale of three stories In the qualitative research, respondents explained what they saw as the underlying reasons for their (different) perceptions. They related their own narrative of how and why the organisations functioned in a particular way. We grouped their remarks into three main narratives that help make sense of these differences and explain why these perceptions recur (cf. Bolton, 2006; Hansen, 2006, pp. 68–72). Such nar ratives are subjective forms of knowledge that help people to make sense of and reflect on their actual experiences. They shape and are shaped by perceptions. Humanitarian action is a tough job, but it gets done Overall, the beneficiary population, as well as Congolese staff of both organisations, held the view that humanitarian action is a necessary, but imperfect tool to save lives and reduce suffering. They felt that the humanitarian organisations are doing their best. The population greatly appreciated that its health needs were being addressed. It noted problems in communication and execution, but all in all the beneficiary population considered the organisations to have good intentions.

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The IRC is perceived as a US organisation and the population often argues that the US administration supports ‘Rwandan aggressors’. Over time, however, the beneficiaries’ perception of the IRC as an independent organisation has increased. The beneficiary population may not often use the terms neutrality, impartiality and independence, but it cares about its health needs, and generally perceives—or at least gives the benefit of the doubt—that both the IRC and Malteser International are working hard not to take sides and to remain independent in a very challenging environment. In addition, local beneficiaries realise that many of the problems, such as low-quality health staff, stock supply depletion, and local health staff charging inappropriate fees, can be addressed and overcome with persistent effort. There is something to say for this narrative, which is also more or less expected outside crisis zones. It derives its strength from the fact that people know they need healthcare and are genuinely appreciative of such assistance and the possibility of gradual improvement. In short, according to this narrative, legitimacy of aid is high and effectiveness is continually improving. However, this narrative does not (fully) explain why the attitudes of health facility staff are more negative than those of the population they serve, and why views are more negative closer to Bukavu, in particu lar among civil society organisations and other local authorities. Whereas according to this narrative aid is not perfect, but can be improved, the following one draws on many of the same elements to imply that humanitarian action lacks impact or even has inherently negative aspects. Humanitarian action addresses effects not causes The IRC’s US background was a cause for suspicion, which was reinforced by its arrival during the war. We actually tried to identify the sources of the criticism of supposed IRC support for Rwanda. Within Bukavu we were sent from one reli gious authority to a civil society organisation, to a local media organisation, to other civil society representatives, and to a government institution, but we never found any solid evidence of the IRC’s supposed role in supporting the Rwandans. Rumours continued unabated in Bukavu, which paradoxically meant that the criticism could neither be proved nor disproved.29 Malteser International faced limited rumours concerning its supposed relation with the FDLR on the way to Nindja. Such rumours of hidden political intentions can be reinforced during the execu tion of humanitarian activities when time of arrival, negotiations with rebels and other armed groups to gain access, the ethnicity of local staff members, logistics (‘Operation Retour’), stock supply depletion (and the resulting difficulties with the cost-recovery system), and exit or hand-over of tasks raise further suspicions of a hidden political or economic agenda. Moreover, local NGOs and authorities argued that humanitarian work does not remove the root causes of the conflict or bring peace. Of course, this is inherent to the traditional humanitarian principles; they concern more the effects than the causes of conflict, and the organisations only become active once conflict rages. As a consequence, civil society actors and some local government officials in Bukavu


and Kabare (a health zone close to Bukavu) contended that humanitarian organisa tions need war to become—and stay—active. Put differently, to them the organisa tions actually benefit from the war, whereas they feel marginalised; their personal and organisational needs are insufficiently being addressed. Hence, this discussion of incompetent execution and lack of impact by not tackling the root causes is actu ally a logically consistent and internally coherent narrative about the shortcomings of humanitarian organisations and their work in general. For these local authorities, the lack of legitimacy concerning the root causes of the violence and ineffective ness in executing humanitarian activities simultaneously reinforce each other. An interesting aspect of this story is the high level of agency it imputes to the humanitarian organisations. That the organisations attempt to uphold the principles of humanity, neutrality, impartiality and independence in order to safeguard their access to the beneficiary population outside Bukavu is not being noticed. Moreover, the indirect effect that donor governments have on the execution of aid, which was frequently mentioned by staff members of both organisations as an organisational con straint, does not receive much attention as an explanatory factor. Humanitarian action as exchange The existence of the above two narratives raises the following question: how can these two stories co-exist? To some extent, this is a political question: those local government officials, civil society organisations, and church leaders that criticise do not have the power to change the local political situation and the functioning of such organisations as the IRC and Malteser International (and it is not certain that they would do a better job). During a focus group in Kaniola, we told several traditional leaders that religious and other local authorities in and around Bukavu were highly critical of the inter national aid organisations. They replied that these authorities felt that they had lost power and were pursuing their own interests. They explained to us that we should carefully assess the interests of those who criticise the humanitarian NGOs, as these interests may not be purely humanitarian. In this respect, there are many actors who benefit from the current humanitarian system: patients receive healthcare, health facility staff members earn some income, people work for both organisations, and donor governments can say that at least they are doing something in the DRC. Moreover, local health staff as well as (parts of ) the population dealt with both organisations in a strategic manner. The beneficiary population and local health personnel in the IRC-supported part of the Mwenga health zone complained about the IRC when it was still active, but according to a local observer this was actually a bid to receive more services. As noted, they now strongly regret the IRC’s departure. In this sense, humanitarian action is a working misunderstanding. On the one hand, various groups of people, not only the patients, benefit. On the other hand, national and international political root causes are not addressed. Furthermore, the donor governments’ deep impact on execution and distribution of aid barely receives

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attention. Many stakeholders in humanitarian action thus attempt to use aid for their own ends, without fully addressing its shortcomings, so that humanitarian action can become a political or economic tool with other uses than just saving lives or reducing suffering. At times, legitimacy and effectiveness, as well as principles, lose relevance; they become pawns in the hands of self-interested actors as different as warlords and donor governments. Frequently, negative local perceptions will then arise, yet humanitarian action can continue, while the broader national and inter national political dynamics are not sufficiently being addressed. In this narrative, humanitarian aid becomes an exchange between different groups of people seeking to realise their own interests (such as help with basic needs, salaries, satisfaction from doing good, political power and military control). Genuine humanitarian action is not impossible in this narrative, but it needs to establish its place—and often it is simply allocated a small spot—among other more selfish or narrow-minded interests (cf. Bass, 2008, pp. 341–351).

Diversity in perceptions explained The existence of these different narratives can be explained in five points: 1. Needs matter most. Medical needs are very important to the beneficiary population. To the extent that these needs are addressed, it is likely to judge the humanitar ian organisations positively. However, needs are not uniform. Other local groups and organisations simply have different needs and interests. Important additional concerns of local health facility staff were their income and the professional execu tion of their work; the local authorities concentrated more on their organisational needs and the overall peace process. In general, the humanitarian focus on phys ical needs makes it harder to take these other types of needs into account. Such different needs shape perceptions in various ways: • Just like needs, all perceptions are local. For example, perceptions in Bukavu differ from those in Kalehe. Hence, perception studies that generalise for a whole coun try or province will typically lack validity and gloss over important differences. • Position determines perception. The CMOs of the health zones generally talked in a more nuanced way about the humanitarian organisations than local health facility staff, because they had more interaction and therefore a better under standing of the functioning and constraints of these organisations. Civil society bodies, church leaders and other local authorities in and close to Bukavu often felt excluded, and had less interaction with the humanitarian NGOs. Moreover, neither organisation supported health services in Bukavu itself, which could have helped to enhance their image there. • Professionalism builds more trust than the humanitarian principles. The way in which aid is executed matters in terms of legitimacy and effectiveness. Proper execu tion (for instance, preventing stock supply depletion or speaking with patients)


simply addresses needs better, and inspires more trust than referring to the prin ciples of humanity, neutrality, impartiality and independence.30 The health zone supervisory staff and local authorities generally know the principles, but the beneficiary population rarely refers to them. Although the beneficiary population may not use the wording of the principles, if it perceives that an organisation is taking sides or fails to meet their medical needs it will clearly hold this against the organisation. • Needs also influence different perceptions of the relationship between humanitarian action and development cooperation. As long as their medical needs are addressed (and health fees are not too high), the transition between humanitarian and devel opment assistance remains a secondary concern of the local population. Staff at the health centres, however, see this transition more critically, because they are more directly (and financially) affected by the new working techniques that mark this transition, such as instituting a cost-recovery system, working under a performance-based supervisory system, and exit and hand-over by a humanitarian organisation to a development organisation. 2. Some criticism about a lack of impact of humanitarian organisations will always remain, because humanitarian action tackles the effects and not the causes of violent conflict and humanitarian crises. Many local actors in Bukavu clearly notice that humanitarian action and its principles are reactive—the organisations came in when the war had started—and do not bring peace. Particularly in long-lasting crises, humanitarian action is by its very nature always open to this type of accusa tion of a lack of impact. Yet, the role of the principles in facilitating access is not being noticed in this criticism. 3. In a low-trust society, where geopolitical rumours help people to make sense of life in a context of continuous insecurity, there will always be either regular activities or incidents that the humanitarian organisations cannot prevent. Perceptions regarding geographical origins, time of arrival, interaction with armed factions and negotiations to gain access, ethnicity of staff, an organisation’s security policies and differences in power (as symbolised by four-wheel drive vehicles), and even stories like Kanyonya, can and will emerge sooner or later. Hence the question ‘What does it mean to be apolitical in a context where people have a hard time believing that such an attitude is actually possible?’ is bound to repeat itself. The preceding text implies the partial solution that needs-based humanitarian action be executed and com municated with empathy and professionalism. 4. Communication matters as a form of expectation management. In general, in chronic crises, continuous communication has to become the norm for humanitarian organisations.31 Ideally, the organisations should discuss how they attempt to use the principles to safeguard access, which (medical or other) needs they address, and what their professional priorities and constraints are. In terms of process, increasing communication with local government officials, NGOs, church and traditional leaders may be more useful than just informing the population. The

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former seems to have a positive multiplier effect, while focusing only on the latter easily leads to higher expectations and concomitant impressions of broken prom ises. In a similar vein, communication with Congolese staff at different levels of the health system can also be improved. 5. The lack of consistent international support, in particular the impact of donor governments on execution, is rarely perceived locally. The agencies thus bear the brunt of local criticism. Stories about the IRC’s US background rarely address this constraint on its execution; instead they immediately deal with the organi sations’ supposed US overlords or the Rwandan aggressors at the international policy level.

Conclusion On the basis of a literature review, this research concentrated on local perceptions of the political and economic roles of two humanitarian organisations active in eastern DRC. The findings indicate that these perceptions and associated narratives can vary considerably. Although the three narratives often draw on similar elements, they reach very different conclusions in terms of effectiveness and legitimacy. Being dependent on perceptions, these narratives cannot easily be disproved, as long as they are logically consistent and internally coherent. Whereas local authorities in eastern DRC often stress their negative perceptions, the beneficiary population judges medical humanitarian aid very positively. Local people frequently do not know the wording of the principles well, but they care deeply about their needs or the organisations taking sides. In this respect, the sub stantive content of the humanitarian principles of humanity, neutrality, impartiality and independence remains salient and useful. In particular, the way in which aid is provided can inspire trust. The more needsbased and professional the manner in which a humanitarian organisation carries out its work, the more behaviour and outcomes are judged positively. The qualita tive analysis indicates possible areas for improvement in this respect. Humanitarian organisations should also communicate the constraints under which they—and the international aid system—operate, especially because in today’s chronic crises, humani tarian organisations are bound to become part of the local context and get caught up in narratives that differ from the way the organisations perceive themselves. Percep tion studies can help the organisations to understand better local diversity and trends, and, thus, to respond more effectively.32

Acknowledgements The authors would like to thank Antonio Donini, Michael Barnett, Steve Hansch and five anonymous reviewers for their suggestions.


Correspondence Dennis Dijkzeul, The Institute for International Law of Peace and Armed Conflict (IFHV), NA 02/29, Ruhr Universität Bochum, 44780 Bochum, Germany. E-mail: [email protected]

Endnotes 1

In current practice, many organisations relevant to humanitarian action, such as the Adventist Development and Relief Agency (ADRA), Africare, CARE, Catholic Relief Services (CRS), Project Concern, Save the Children, and World Vision, do see themselves as likely to be around for a very long time. Other organisations, such as Action Contre la Faim (ACF) and Médecins Sans Frontières (MSF), intend to stay for the short(er) term. 2 Arguably, humanitarian organisations conduct an enormous amount of ‘research’ on local condi tions, in particular local assessment and monitoring data. This research, however, rarely gets cited in international forums or published by political science or international relations journals. 3 This is also true of related fields that concern themselves with crises and conflicts. Goodhand (2006, p. 159) argues that only limited systematic analysis has been carried out ‘between aid inter ventions and the dynamics of peace and conflict’. Especially at the local micro-level such research has been lacking. In addition, local perceptions have often been neglected in international peace building efforts, hampering their effectiveness (Talentino, 2007). Similarly, Mac Ginty argues that ‘[t]he implementation of [a] peace accord becomes a technocratic exercise of ticking boxes, counting heads and weapons, amending constitutions, and reconstructing housing units, while the more thorny affective and perceptual issues of reconciliation, exclusion, and the restoration of dignity are left unaddressed’ (Mac Ginty, 2006, pp. 3–4). Moreover, the International Committee of the Red Cross (ICRC)’s ‘People on War’ project was instigated 50 years after the signing of the Geneva Conventions in 1949, when ‘after decades of working and speaking for people affected by armed conflict, the ICRC felt it was time to seek views on the limits in war from the victims them selves’ (see Greenberg Research Inc., 1999). 4 Public health/medical studies on healthcare access, quality, delivery, and cost recovery frequently touch on local perceptions, in particular Knowledge, Attitudes and Practice (KAP) studies, but public health outcome or impact measures would usually be lives saved, disease incidence, casefatality rates, and ‘compliance’ or utilisation rates. Broader anthropological or sociological approaches to perception are simply not their main focus (cf. Van Herp et al., 2003; Dijkzeul and Lynch, 2006a; Litvack and Bodart, 1993). 5 This research was part of a cooperative effort to develop a generic field guide to analyse refugees’ views of healthcare services (see Williams and Burke, 2002). 6 The redistribution of food aid is probably as old as food aid itself, but the evaluations detailing this have only become widely available since the advent of the internet. 7 Perceptions also played an implicit role in the Do No Harm approach (Anderson, 1999), for example in its analysis of implicit ethical messages and the role of values and experiences. CDA Collabora tive Learning Projects has also initiated the ongoing ‘Listening Project’ (Anderson, 2009). 8 See http://www.fritzinstitute.org/prgHumanitarianImpact.htm. 9 See http://www.alnap.org/publications/participation_study.htm. Its six country case studies and Handbook for Practitioners are all from 2003–04. 10 See Catley et al. (2008) for information on participatory impact assessment, as well as Jaspars and Maxwell (2008) and Frize (2008), who investigate the participation of recipient communities in the targeting and management of humanitarian food assistance.

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In particular principle 7: ‘Ways shall be found to involve programme beneficiaries in the manage ment of relief aid’ (Sphere Project, 2004, p. 319). Also see ‘Recognising vulnerabilities and capacities of disaster-affected populations’ (Sphere Project, 2004, p. 9). 12 In their study of participation in eastern DRC, Mugiraneza and Levy (2003, pp. 57–58) show that staff of local NGOs and government agencies do not feel involved in the decisions and actions of international aid actors. 13 Refugees have probably received more attention than internally displaced persons (IDPs), because refugees have been studied for a longer period of time, and IDPs are generally harder to reach, because they have to stay in their (insecure) country of origin. For natural disasters, it may be that in these crises the traditional approach of ‘coming in, saving lives and leaving’, with the govern ment and development organisations subsequently taking over, gave rise to the impression that knowing the local context, including local perceptions, is less important. 14 Understanding local perceptions partly overlaps with measuring impact. In line with the discus sion about the degree to which negative perceptions are inevitable, it is possible for a programme to have a negative local perception but a positive impact (for example, people do not always want latrines, or prefer injections over cheaper and equally or more effective pills). Perceptions and impact are (and should be seen as) strongly linked, but should not be conflated. 15 Even methodologically rigorous studies, such as the IRC mortality studies from the DRC (Coghlan, Brennan and Ngoy, 2006; Coghlan et al., 2008) have had to deviate from their planned procedures with decisions made daily as a function of conditions in the field. 16 Moreover, perception studies are seldom carried out regularly, so that baseline and trend infor mation on humanitarian organisations and their work rarely exists, if at all. 17 Reliability ‘refers to whether or not you get the same answer by using an instrument to measure something more than once’ (Bernard, 2002, p. 50). Hence, replicability (the fact that one can do the research again) is a precondition for reliability. We took great care to make our research instru ments as replicable as possible, by ensuring that the same or similar research can take place at the same locations and among organisations and/or staff members in the same professional positions. 18 For more details about the Congolese health system, see Van Herp et al., 2003; Coghlan, Brennan and Ngoy, 2006; and Dijkzeul and Lynch, 2006a, 2006b. 19 The IRC is also conducting local capacity-building projects (Dijkzeul, 2005). 20 An IRC staff member also informally supplied contact information for local rental car providers and drivers. 21 The three questionnaires were partly based on the questionnaires developed by the Feinstein Inter national Center’s ‘Agenda 2015’ project. They were piloted with staff members of both organisations and with local stakeholders during one day of field research. 22 A health committee consists of representatives of the local population and it is involved in the management and control of a health facility. 23 The last three days of research were spent on data tabulation and initial analysis. Further analysis and writing of the paper took place from September 2007 to April 2008 and again from December 2008 to January 2009. 24 For example, we visited one health centre where a victim of violence, accused of witchcraft, had been brought. She was losing blood quickly, and without other cars in the vicinity, the head nurse asked us to bring the woman to the hospital for blood transfusions, which we did. 25 Normally, our interviews took place in French. Patient and non-patient beneficiary interviews, however, took place in Swahili and once in Kirega and once in Mashi. 26 Normally, only one international organisation is active in a health zone (Mwenga was the exception that proved the rule), so the population did not indicate many other organisations active in their zone. The IRC happened to be known in all zones, but in the zones where it was not carrying out health activities, people indicated that they knew about it, but did not have any practical expe rience of it (except in a few instances with water and sanitation work).


27

When we asked from which organisations in general the population would like to receive aid— and we had formulated a long list of possible local and international organisations—80 per cent did not have any preference and 20 per cent did not know. When asked to explain this answer the general response can be summarised as ‘we are poor, we cannot be choosy, and we need all the help we can get’. 28 This issue came up spontaneously with health staff. We did not have specific questions on this issue for either health staff or local beneficiaries. For the official IRC position, see http://www.theirc. org/where/the_irc_in_democratic_republic_of_congo.html. 29 Nobody referred to Chester (1995) or to articles in the Congolese media about this issue. 30 Hilhorst (2005, pp. 357–359) makes a similar argument about the way in which the more devel opmental principles in the Code of Conduct for the International Red Cross and Red Crescent Movement and Non-Governmental Organizations (NGOs) in Disaster Relief—respect for local culture (Article 5), working with local partners (Article 6), a participatory approach (Article 7) and accountability (Article 9)—can foster trust. 31 Stockton (2003, pp. 50–52) provides an analysis along similar lines. 32 For humanitarian action in general, it would be ideal if perception studies could become an inte gral part of standards, accreditation and certification processes, such as those of the Humanitarian Accountability Project (HAP), and evaluations. From a methodological point of view, this would facilitate simultaneously the independence of the research and cooperation by the humanitarian organisations.

References Allen, T. and H. Morsink (eds.) (1994) When Refugees Go Home: African Experiences. United Nations Research Institute for Social Development (UNRISD), Geneva, with James Currey, London, and Africa World Press, Trenton, NJ. Allen, T. and D. Turton (1996) ‘Introduction. In Search of Cool Ground’. In T. Allen (ed.) In Search of Cool Ground. War Flight and Homecoming in Northeast Africa. James Currey, London, and Africa World Press, Trenton, NJ. pp. 1–22. Anderson, M.B. (1999) Do No Harm: How Aid Can Support Peace—Or War. Lynne Rienner Publishers, Boulder, CO. Anderson, M.B. (2009) ‘The Giving–Receiving Relationship: Inherently Unequal?’. In Development Assist ance Research Associates (ed.) (2009) The Humanitarian Response Index 2008. Palgrave Macmillan, Basingstoke. pp. 97–105. Autesserre, S. (2008) ‘The trouble with Congo’. Foreign Affairs. 87(3). pp. 94–110. Bakewell, O. (2000) ‘Uncovering local perspectives on humanitarian assistance and its outcomes’. Disasters. 24(2). pp. 103–116. Barnett, M. (2005) ‘Humanitarianism transformed’. Perspectives on Politics. 3(4). pp. 723–740. Bass, G.J. (2008) Freedom’s Battle: The Origins of Humanitarian Intervention. Alfred A. Knopf, New York, NY. Bernard, H.R. (2002) Research Methods in Anthropology: Qualitative and Quantitative Approaches. Third edition. Altamira Press, Walnut Creek, CA. Bolton, G. (2006) ‘Narrative writing: reflective enquiry into professional practice’. Educational Action Research. 14(2). pp. 203–218. Bos, P.L.J. (2003) Crisis Management in a Crowded Humanitarian Space: The Politics of Hosting Refugee Influxes. Crismart, National Defence College, Stockholm. Catley, A., J. Burns, D. Adebe and O. Suji (2008) Participatory Impact Assessment: A Guide for Practitioners. Feinstein International Famine Center, Tufts University, Boston, MA.

1167

1168


Chester, E.T. (1995) Covert Network: Progressives, the International Rescue Committee, and the CIA. M.E. Sharpe, Armonk, NY. Coghlan B., R.J. Brennan and P. Ngoy (2006) ‘Mortality in the Democratic Republic of Congo: a nationwide survey’. The Lancet. 367(9504). pp. 44–51. Coghlan B. et al. (2008) Mortality in the Democratic Republic of Congo: An Ongoing Crisis. International Rescue Committee (IRC)/Burnett Institute, in mimeo. de Waal, A. (1997) Famine Crimes: Politics & the Disaster Relief Industry in Africa. James Currey, Oxford. Dijkzeul, D. (2005) Models for Service Delivery in Conflict-affected Environments: Drawing Lessons from the Experience of the Ushirika/GBV Partnership Programmes in the Eastern Democratic Republic of the Congo. Consultancy report for the IRC and the UK Department for International Development (DFID), in mimeo, Bukavu. pp. 1–101. Dijkzeul, D. and M. Moke (2005) ‘Public communication strategies of international humanitarian organisations’. International Review of the Red Cross. 87(860). pp. 673–691. Dijkzeul, D. and C. Lynch (2006a) Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in Eastern Democratic Republic of the Congo. The National Academies Press, Washington, DC. Dijkzeul, D. and C. Lynch (2006b) ‘NGO management and healthcare financing systems in DRC’. Global Public Health. 1(2). pp. 157–172. Donini, A. (2007) ‘Local perceptions of assistance to Afghanistan’. International Peacekeeping. 14(1). pp. 158–172. Donini, A., L. Minear and P. Walker (2004) ‘The future of humanitarian action: mapping the impli cations of Iraq and other recent crises’. Disasters. 28(2). pp. 190–204. Donini, A., L. Minear, I. Smillie, T. van Baarda and A.C. Welch (2005) Mapping the Security Environment. Feinstein International Famine Center, Tufts University, Boston, MA. Donini, A. et al. (2006) Humanitarian Agenda 2015: Principles, Power, and Perception. Feinstein Inter national Center, Tufts University, Boston, MA. Donini, A. et al. (2008) Humanitarian Agenda 2015 Final Report: The State of the Humanitarian Enterprise. Feinstein International Center, Tufts University, Boston, MA. Frangonikolopoulos, C.A. (2005) ‘Non-governmental organisations and humanitarian action: the need for a viable change of praxis and ethos’. Global Society. 19(1). pp. 49–72. Frize J. (2008) Targeting in Complex Emergencies: Colombia Country Case Study. Feinstein International Famine Center, Tufts University, Boston, MA. Fuchs-Heinritz, W., R. Lautmann, O. Rammstedt and H. Wienold (eds.) (1994) Lexikon zur Soziologie. Third edition. Westdeutscher Verlag, Opladen. Gizelis, T.-I. and K.E. Kosek (2005) ‘Why humanitarian interventions succeed or fail: the role of local participation’. Cooperation and Conflict. 40(4). pp. 363–383. Guttieri, K. (2005) ‘Humanitarian space in insecure environments: a shifting paradigm’. Strategic Insights. IV(11). http://www.nps.edu/Academics/centers/ccc/publications/OnlineJournal/2005/Nov/ guttieriNov05.html (accessed on 25 February 2009). Goodhand, J. (2006) Aiding Peace? The Role of NGOs in Conflict. Lynne Rienner Publishers, Boulder, CO and London. Greenberg Research Inc. (1999) The People on War Report: ICRC Worldwide Consultation on the Rules of War. International Committee of the Red Cross, Geneva. Hanlon, J. and H. Yanacopulos (2006) ‘Introduction’. In H. Yanacopulos and J. Hanlon (eds.) Civil War, Civil Peace. James Currey, Oxford, and Ohio University Press, Athens, OH. pp. 7–18. Hansen, L. (2006) Security as Practice: Discourse Analysis and the Bosnian War. Routledge, Abingdon. Harragin, S. and C.C. Chol (1998) The Southern Sudan Vulnerability Study. Save the Children Fund UK, South Sudan Programme, Nairobi. Harrel Bond, B.E. (1986) Imposing Aid: Emergency Assistance to Refugees. Oxford University Press, Oxford.


Henry Dunant Centre for Humanitarian Dialogue (2003) Humanitarian Engagement with Armed Groups: The Central Asian Islamic Opposition Movements. HD Study. Henry Dunant Centre for Humanitarian Dialogue, Geneva. Hilhorst, D. (2005) ‘Dead letter or living document? Ten years of the code of conduct for disaster relief ’. Disasters. 29(4). pp. 351–369. Humanitarian Initiatives, Disaster Mitigation Institute and Mango, UK (2001) Independent Evaluation: The DEC Response to the Earthquake in Gajarat, Volumes I–III. Disasters Emergency Committee, London. ICG (International Crisis Group) (2007) Congo: Bringing Peace to North Kivu. Africa Report No. 133. 31 October. http://www.crisisgroup.org/~/media/Files/africa/central-africa/dr-congo/Congo%20 Bringing%20Peace%20to%20North%20Kivu.ashx (accessed on 24 February 2009). Jaspars, S., and D. Maxwell (2008) Targeting in Complex Emergencies: Somalia Country Case Study. Feinstein International Famine Center, Tufts University, Boston, MA. Litvack, J.I. and C. Bodart (1993) ‘User fees plus quality equals improved access to health care: results of a field experiment in Cameroon’. Social Science and Medicine. 37(3). pp. 369–383. Macrae, J. (1998) ‘The death of humanitarianism? An anatomy of the attack’. Refugee Survey Quarterly. 17(1). pp. 24–32. Mac Ginty, R. (2006) No War, No Peace: The Rejuvenation of Stalled Peace Processes and Peace Accords. Palgrave Macmillan, Houndmills. Minn, P. (2007) ‘Toward an anthropology of humanitarianism’. Journal of Humanitarian Assistance. 6 August. http://jha.ac/2007/08/06 (accessed on 17 September 2007). Mowjee, T. (2007) Humanitarian Agenda 2015: Democratic Republic of Congo Country Study. Feinstein International Famine Center, Tufts University, Boston, MA. Mugiraneza, C. and K. Levy (2003) ALNAP Global Study: The Case of Eastern Democratic Republic of Congo. Overseas Development Institute, London. Nienhaus, V. (1998) ‘External control through markets’. In Network on Humanitarian Assistance (ed.) Management in Humanitarian Assistance. Second edition. Office for Official Publications of the European Communities, Luxembourg. pp. 29–34. Okumu, W. (2003) ‘Humanitarian international NGOs and African conflicts’. International Peacekeeping. 10(1). pp. 120–137. Operations Review Unit (1994) Humanitarian aid to Somalia. Ministerie van Buitenlandse Zaken, Inspectie Ontwikkelingssamenwerking te Velde, The Hague. Osman, M. (2006) ‘The developing world—Western NGOs and Islam: how to counter the image of “missionaries and spies”’. Europe’s World. Autumn. http://www.europesworld.org/EW Settings/Article/tabid/78/Default.aspx?Id=ef0c45d1-ec42-4f51-a66d-d0812da17c6d (accessed on 8 August 2007). Pottier, J. (1996a) ‘Relief and repatriation: views by Rwandan refugees; lessons for humanitarian aid workers’. African Affairs. 95(380). pp. 403–429. Pottier, J. (1996b) ‘Why aid agencies need better understanding of the communities they assist: the experience of food aid in Rwandan refugee camps’. Disasters. 20(4). pp. 324–337. Richards, P. (2005) No Peace, No War: An Anthropology of Contemporary Armed Conflicts. Ohio University Press, Athens, OH. Roberts, L. and M. Despines (1999) ‘Mortality in the Democratic Republic of the Congo’. The Lancet. 353(9171). pp. 2249–2250. Rogge, J.R. (1994) ‘Repatriation of refugees: a not so simple “optimum” solution’. In T. Allen and H. Morsink (eds.) When Refugees Go Home: African Experiences. UNRISD, Geneva, in association with James Currey, London, and Africa World Press, Trenton, NJ. pp. 14–49. Rutta, E. et al. (2005) ‘Refugee perceptions of the quality of healthcare: findings from a participa tory Assessment in Ngara, Tanzania’. Disasters. 29(4). pp. 291–309.

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Savage, K. with M.S. Jackollie, D.M. Kumeh and E. Dorbor (2007) Corruption perceptions and risks in humanitarian assistance: a Liberia case study. Humanitarian Policy Group (HPG) Background Paper. April. ODI, London. Schloms, M. (2003) ‘Humanitarian NGOs in peace processes’. International Peacekeeping. 10(1). pp. 40–55. Slim, H. (2003) Humanitarianism with Borders? NGOs, Belligerent Military Forces and Humanitarian Action. Paper for the International Council of Voluntary Agencies (ICVA) Conference on ‘NGOs in a chang ing world order: dilemmas and challenges’, Geneva, Switzerland, 14 February. http://www.jha. ac/articles/a118.htm (accessed on 17 September 2007). Slim, H. (2004) How we Look: Hostile Perceptions of Humanitarian Action. Presentation to the ‘Conference on humanitarian coordination’, Wilton Park Montreux, 21 April. http://www.reliefweb.int/rw/ lib.nsf/db900sid/AMMF-6VEJH9/$file/HDC-Apr2004.pdf?openelement (accessed on 25 Feb ruary, 2009). Sperl, S. (2002) ‘International refugee aid and social change in northern Mali.’ Refugee Survey Quarterly. 21(1–2). pp. 147–159. Sphere Project (2004) Humanitarian Charter and Minimum Standards in Disaster Response. Sphere Project, Geneva/Oxfam Publishing, Oxford. Stockton, N. (2003) Humanitariansim Bound: Coherence and Catastrophe in the Congo. Draft United Nations document, in mimeo. Talentino, A.K. (2007) ‘Perceptions of peacebuilding: the dynamic of imposer and imposed upon.’ International Studies Perspectives. 8(2). pp. 152–171. Turner, S. (1998) ‘Representing the past in exile: the politics of national history among Burundian refugees.’ Refuge. 17(6). pp. 22–29. Turner, S. (2004) ‘Under the gaze of the ‘big nations’: refugees, rumours and the international com munity in Tanzania’. African Affairs. 103. pp. 237–247. Turner, T. (2007) The Congo Wars: Conflict, Myth and Reality. Zed Books, London. Uvin, P. (1998) Aiding Violence: The Development Enterprise in Rwanda. Kumarian Press, West Hartford, CT. Van Herp, M., V. Parque, E. Rackley and N. Ford (2003) ‘Mortality, violence and lack of access to health-care in the Democratic Republic of Congo’. Disasters. 27(2). pp. 141–153. Walkup, M. (1997) ‘Policy dysfunctions in humanitarian organisations: the role of coping strategies, institutions, and organisational culture’. Journal of Refugee Studies. 10(1). pp. 37–60. Weiss, T.G. and P.J. Hoffman (2007) ‘The fog of humanitarianism: collective action problems and learning-challenged organisations’. Journal of Intervention and Statebuilding. 1(1). pp. 47–65. Williams, H. and H. Burke (2002) A Field Experience – Assessing Refugees’ Health Care Services In Tanzania: A Field Guide. Health and Community Development Section, Division of Operation and Support, United Nations High Commissioner for Refugees, Geneva.