Containing COVID-19 in the Democratic Republic of the Congo: Government Measures and Women's Compliance

Abstract

This article concerns the unfolding COVID-19 pandemic in the Democratic Republic of the Congo. It analyses the sanitary measures that the government has taken to respond to the pandemic since March 2020, the way these measures are enforced, and the extent to which women comply with the measures. The article draws from desk research and empirical data from the eastern city of Bukavu, where the research team conducted 134 structured interviews. The findings show widespread willingness to comply with some of the main measures because of fear of sanctions, fear of the pandemic and because of trust in the state or church. The article argues that many women hold the state accountable for the success in containing the virus, but also criticize the state for not providing livelihood assistance during the state of emergency. Further research is needed to assess the impact of COVID-19 on state legitimacy.

INTRODUCTION

When the contours of the COVID-19 pandemic started to take shape globally in March and April 2020, most African governments were quick to take stringent measures to control the outbreak, even when caseloads were still low.¹ The first COVID-19 case in the Democratic Republic of the Congo (DRC) was reported on 10 March 2020.² On 18 March, the DRC had 14 hospitalized patients diagnosed with COVID-19, all based in the capital, Kinshasa. Nevertheless, the president already announced strict measures throughout the country in an official message to the nation.³ Six days later, when the total number of infected people in the capital had increased to 45, a state of emergency was declared for the whole country through Ordinance No 20/014.⁴ The state of emergency was renewed six times and ended on 22 July 2020.⁵ However, even after then, a number of measures remained in place. What happened during this period? How did Congolese citizens experience the pandemic and measures that were taken against it, and to what extent did they comply with the measures? What does this tell us about the way in which people view the state? This article provides a discussion of the sanitary measures that the Congolese government put in place to curb the COVID-19 pandemic, and analyses women's compliance and their opinions about the government. The study provides a unique opportunity to further knowledge about law enforcement and compliance during a global pandemic in a developing and conflict-affected country, where the state has limited capacity and contested legitimacy. Lessons from the unfolding pandemic in the DRC can be of use to other countries and for future responses by state and non-state actors. A note of caution remains. Since the pandemic is still unfolding, this study should be taken as a preliminary snapshot of a phenomenon that deserves further research. The article provides suggestions for directions that could be taken in this regard.

The empirical research focused especially on women. They bear the highest burden of (unpaid) care and are therefore highly affected by the pandemic and its consequences. The UN secretary-general summed this up very clearly: “[a]cross every sphere, from health to the economy, security to social protection, the impacts of COVID-19 are exacerbated for women and girls simply by virtue of their sex”.⁶ About 70 per cent of the health workforce globally is constituted by women, which makes women more exposed to the virus.⁷ It is clear that the pandemic has negative economic effects globally, but a recent report on gender equality shows that women are 1.8 times more likely to be affected by loss of employment due to the pandemic.⁸ Sexual and gender-based violence, especially in the domestic sphere, have increased. It has even been described as “the shadow pandemic” in a major campaign launched by UN Women.⁹ An additional reason to focus on women relates to the observation that any response risks being less effective, and even harmful, if it is does not address women. This is even more the case in fragile and conflict-affected settings such as the DRC.¹⁰ The Global Humanitarian Response Plan COVID-19, proposed by the UN Office for the Coordination of Humanitarian Affairs (UNOCHA), underlined the need to pay particular attention to “women, adolescents and people with disability” and to ensure that they participate in needs assessment and responses.¹¹ In summary, it is clear that women have higher interests in the successful containment of the virus, but also play an important role in effective containment.

The DRC context

The DRC is a country in which trust in the government is generally low, especially in the eastern provinces. A large number of armed groups of varying configurations, and with varying spheres of influence, compete with each other and with the government's armed forces over control of people, land and resources in the east of the country.¹² Conflicts have continued with different levels of intensity since the First and Second Congo Wars that started in the 1990s, leading to high levels of insecurity and violence and to the large-scale displacement of people.¹³ It is not surprising that, in this context, people report low levels of trust in the government, whether in respect of the provision of justice and security, or in relation to other aspects of life. A large, population-based survey¹⁴ in the east of the country showed for instance that, in 2019, only 22 per cent of respondents felt that their village or neighbourhood was peaceful; 8 per cent indicated that eastern DRC in general was peaceful; of the Bukavu-based respondents only 10 per cent were positive about the government's peacebuilding efforts.¹⁵ Only 8 per cent of respondents were positive about the government's efforts to combat poverty, 9 per cent were positive about job creation and 8 per cent about the fight against corruption.¹⁶ State institutions such as the courts or the police have to work with limited budgets, are understaffed and often have a low reputation among the population.¹⁷ When it comes to basic services, it is also noted that people have limited trust in the capacity of the government. Another population-based survey at different sites in the east of the DRC showed that 82 per cent of respondents did not agree that the “government does everything it can to improve education”.¹⁸ The same survey showed that 72 per cent did not agree that the “government does everything it can to improve health care”.¹⁹

The provision of basic public services such as health, education or water is largely not in the hands of the Congolese government. Even in colonial times, the state outsourced education and healthcare, mostly to faith-based organizations (especially the Catholic and Protestant churches). After a short interruption, the post-colonial state under Mobutu continued this practice.²⁰ During Mobutu's reign, the Congolese government made efforts to establish a system of public healthcare that ran into the smallest pockets of society, dividing the country into decentralized health zones. This system still exists today. It was initially praised as an example of the organization of public healthcare in Africa, but has been increasingly criticized for being predatory and malfunctioning. It also became increasingly privatized, with both churches and (international) non-governmental organizations (NGOs) taking over the actual functioning of the majority of the health zones.²¹ However, in general terms, Congolese people are fairly positive about the provision of healthcare in the country, also when compared with other public service sectors.²² The government currently sets the regulatory frameworks for both education and healthcare, but non-state actors operate the services and are largely funded through user fees.²³

Congo's previous Ebola outbreaks meant that the government and population had some experience of dealing with contagious respiratory viruses. A more than two-year outbreak of Ebola that started in North Kivu province as early as May 2018 was still ongoing when Congo detected its first cases of COVID-19 in Kinshasa.²⁴ This Ebola outbreak happened in an area that had not previously experienced any Ebola outbreaks and health workers had limited knowledge of the experience that had been gained elsewhere in the country during previous epidemics.²⁵ When the epidemic gained momentum, fear built up in the major cities in the east of the country (Goma and Bukavu) that the epidemic could spread there as well. As a result, sanitary measures were put in place, such as temperature checks at important border crossings, hand-washing stations at entrances to public buildings and other places with frequent visitors such as offices and hotels. The city of Bukavu for instance was quickly dotted not only with hand-washing stations, but also with educational material to raise awareness among the population about the risks of Ebola. These measures were largely still in place when COVID-19 started to gain momentum.

The next section of this article consists of two parts. The first provides the theoretical background to this article, introducing the concept of compliance and what this says about state legitimacy. The second part discusses comparable findings on compliance with sanitary measures during recent Ebola epidemics in different countries in Africa, including the DRC. The article then introduces the research approach and the location at which empirical data gathering took place. The next section describes and analyses the sanitary measures that were taken by the government during and after the Congolese state of emergency to contain the COVID-19 pandemic in the country. The article then presents empirical findings on: women's knowledge about COVID-19; their willingness to comply (or not) with sanitary measures; and women's opinions of the government. The following section returns to the main questions and analyses the preliminary findings in relation to the theoretical framework on compliance. The article concludes by discussing policy implications and providing suggestions for further research.

COMPLIANCE, LEGITIMACY AND PUBLIC SERVICES IN THE CONTEXT OF A FRAGILE STATE

To contain the COVID-19 pandemic, governments worldwide face the question of which measures to take to reduce levels of infection and to ensure that people comply with those measures. By declaring a state of emergency, governments can quickly adopt legislation that deals with an urgent issue such as an epidemic. This is indeed the path that many African governments, including the government of the DRC, have chosen.²⁶ Two main factors can probably explain the swift action that was taken in Africa: the fear of overburdening understaffed and underfunded healthcare systems; and the expert knowledge and experience available in Africa to fight diseases such as HIV/AIDS, malaria, Lassa fever and Ebola. Both factors contributed to awareness of the urgency to address COVID-19 at an early stage.²⁷

What do we know about the way in which compliance works? Put very broadly, there are two perspectives on why people obey the law, as set out in the seminal work by Tyler: an instrumental and a normative perspective.²⁸ From the instrumental perspective, often taken by policymakers, it is assumed that people obey the law on the basis of weighing up the consequences of law violation. The greater the deterrent these consequences present (high fines, severe punishment, strict sanctions) and the higher people assess the chances of being caught, the more likely it is that they will comply with the law. From a normative perspective, people comply with the law because they agree with the law. From this perspective, there are two main reasons why people might agree. First, the behaviour that the law prescribes is in line with people's personal moral ideas about what is right and wrong, and they are therefore automatically willing to comply. Secondly, people might agree with the law for reasons of legitimacy: people trust that the government imposes laws that are good for their constituency.²⁹

As rightly pointed out by Ostermann, much of the compliance literature builds on research findings from the developed world. In these settings, “state enforcement capacity is substantial and remains largely undiminished by corruption” and the use of deterrence measures to enforce the law is generally limited.³⁰ Literature on compliance often assumes that deterrence is not frequently used to achieve compliance, because people are already inclined to obey the law for normative reasons. However, in the context of a more fragile state, such normative compliance is not self-evident. The question, then, is whether general theories about compliance work in the same way in developing and conflict-affected countries. And whether they also apply in countries where people have limited trust in the state because the state is seen to be weak. Ostermann's work on compliance with regulations governing the forest in the Indian-Nepali border region shows that states do not necessarily need to have strong capacity to enforce the law, but that it might also be an option to reduce compliance costs.³¹ Applied to compliance with coronavirus measures, this could mean, for instance, that making face masks available for free, or at very low cost, could help to convince people to comply with an obligation to wear face masks in public spaces. This would be regardless of the fines that are levied for people who refrain from wearing a mask in public, and regardless of what people actually think of the obligation. This line of thinking could be seen as a complementary, pragmatic, way to ensure compliance, in which people make a rational choice on the basis of weighing up costs and benefits.

An instrumental approach needs strong law enforcement and it is clear that people's perceptions about state legitimacy are closely associated with legal compliance. What remains less clear though (as argued by Nagin and Telep on the basis of an extensive review) is exactly how this relationship is shaped and whether there is a causal connection whereby improvements in procedural justice lead to more compliance.³² For them, the question remains open: if the police (as the state's public face that imposes order) treat people more fairly, will people notice this and subsequently also think more positively about the state? In response to Nagin and Telep's review paper, Tyler argues that, instead of looking at the body of evidence from criminology, it might also be helpful to include studies from other disciplines, such as psychology (and sociology, the authors would add). On the basis of such studies, Tyler argues that improving community engagement can increase legitimacy and improve compliance without the use of force.³³ If evidence on this in developed countries is already scarce, evidence from developing countries and fragile states is even more scarce,³⁴ while it is in these settings that increasing state legitimacy is especially challenging.³⁵

A normative approach either needs high levels of state legitimacy, or good knowledge or understanding of the rationale behind a rule: if people have knowledge about the reason why a certain rule is in place, they might be more inclined to follow it.³⁶ Next, if people feel that certain rules make sense (for instance because they agree that the rule will reduce the risk of infection) and internalize that, this will lead to a moral orientation that will again increase compliance.³⁷ Awareness raising campaigns by both state and non-state actors can help to increase people's knowledge of COVID-19, symptoms, modes of transmission and sanitary measures.

Achieving compliance through high levels of legitimacy is less easily achieved than through the modes of compliance described above. State legitimacy needs to be built over time and cannot necessarily be enhanced in simple ways during an epidemic. It certainly cannot be imposed. It is often assumed that the provision of basic public services, such as justice and security, healthcare and education, can contribute to state legitimacy, as it is through these services that a state can make itself visible to its citizens.³⁸ People shape their view of the state on the basis of their experiences with the provision of basic public services.³⁹ This is a line of thinking that is also followed by the Organisation for Economic Co-operation and Development, which stated in a discussion paper: “[p]ublic services underpin the social contract between states and citizens and, as such, are an indicator of the health of a society. Grossly inadequate service delivery signals fragility”.⁴⁰ It suggests that better public services, such as better healthcare, might contribute to state legitimacy. This line of thinking is not completely uncontested, and a clear understanding on causality and the correlation between public services and legitimacy is still lacking and probably depends on many contextual factors.⁴¹ However, if legitimacy does not contribute much to compliance, this raises the question of whether the successful containment of COVID-19 (as a public service) can contribute to a more positive image of the state and subsequently increase state legitimacy, thus improving levels of compliance.

Lessons from Ebola epidemics

Whereas many western governments were caught unprepared by the COVID-19 pandemic, several African governments have recent experience of containing epidemics through large-scale public health measures. This section takes stock of whether any lessons can be drawn from recent Ebola outbreaks in West Africa and the DRC.

Based on a survey of public health and public trust carried out in Liberia during the 2014–15 Ebola epidemic in Monrovia, Blair et al show that Liberians who trust the government are more likely to comply with preventive measures such as social distancing.⁴² This assumes that the path towards compliance here was through state legitimacy. They also show that better knowledge about the disease and its modes of transmission did not necessarily lead to better compliance if people did not trust the government enough. Studying the same epidemic in Liberia, Guinea and Sierra Leone, Flückiger et al show that state legitimacy increased in areas with high levels of exposure to the Ebola epidemic. They argue that this is not a direct result of the epidemic itself, but rather because of changing perceptions about the government's response, and possibly the response by non-state humanitarian actors. Hence the epidemic provides an opportunity for the state to show a good face.⁴³

The major Ebola outbreak in the northeast of the DRC that started in 2018 evolved in an area with particularly low levels of government trust due to sustained high levels of insecurity and severe violence in recent years, which continue today. A population-based survey in this area showed that only about a third of respondents trusted that local authorities represented their interests, and those with limited trust in institutions were less likely to accept preventive measures against Ebola.⁴⁴ In this area, mistrust and misinformation played a major role in the challenges the government faced in executing its health policy. In the initial stages of the Ebola outbreak however, people in this region were actually fairly positive about health workers,⁴⁵ as is the case in most parts of the country,⁴⁶ but when health workers started to be accompanied by armed civil protection escorts in insecure areas, people's perceptions changed, also due to rapidly spreading misinformation about the alliance between health workers and the army.⁴⁷ This made it more difficult for non-state health actors to overcome the distrust that state institutions had been facing: a situation that was further aggravated by the complex powerplay at stake in the region.⁴⁸

In summary, findings from both the DRC and West Africa provide insight to the relationship between compliance on the one hand and legitimacy and trust on the other, but also show diverging trends. This underlines the importance of carrying out an analysis of the context to understand compliance dynamics better. The Ebola epidemic in the DRC might be relatively close to Bukavu, but some characteristics of this region are fundamentally different from Bukavu (especially in terms of insecurity and government mistrust). The region in which the Ebola epidemic unfolded is particularly volatile and it therefore cannot simply be assumed that findings from Bukavu will show similar results. A more in-depth comparison would be required for a full understanding of differences and similarities.

METHOD AND RESEARCH LOCATION

This article is based on a desk review of relevant COVID-19 resources (policy documents, ministerial decisions and official government statements), as well as empirical data. Data were coded and analysed with qualitative data analysis software (ATLAS.ti 9). This helped to distinguish patterns and trends in a systematic way. The empirical data consist of 134 structured interviews conducted with women in the three different communes of the city of Bukavu in the first two weeks of September 2020. Apart from demographics, the questions related to three main topics: women's knowledge about COVID-19 and the sanitary measures in place; women's opinions about the government; and healthcare provision in general.

Bukavu is the capital city of the South Kivu Province in the east of the DRC, located on the Congolese-Rwandan border. It is estimated to have more than one million inhabitants. Cross-border trade is intense and the city's economy has a strong outward orientation: food crops come from both the rural parts of the province and from neighbouring districts in Rwanda; and consumer goods are imported via road from Tanzania's coastal harbours to serve Bukavu and its hinterland. International visitors are numerous in the city; NGO workers and mining company personnel regularly pass through the city. Most international visitors arrive via the airport of Kamembe, which is located just across the border in Rwanda. With its connections to the global economy, Bukavu was considered one of the cities in the DRC that was most at risk for COVID-19. It was no coincidence that the first cases of COVID-19 in the DRC, as elsewhere in Africa, were connected to international travel.

THE RESPONSE OF THE CONGOLESE GOVERNMENT TO COVID-19

When the contours of the global reach of COVID-19 started to become clear, alarming and bleak scenarios were sketched for Africa: about mortality rates, overburdened healthcare and the manifold negative side-effects of the disease. Thus far, these scenarios have not turned into reality and leave experts puzzled as to the reasons why the epidemic seemed to take a different path in Africa from elsewhere.⁴⁹ What is clear is that most African governments were quick to take strict and drastic measures, even without having any confirmed cases: many countries closed their international borders, imposed curfews and closed schools, for instance.⁵⁰ The DRC is a clear example of such a country. This section analyses the Congolese legal and policy framework that was set up in response to the pandemic.

Swift action was taken in the DRC. On 10 March 2020, the day on which the first positive case was detected in Kinshasa, the government announced its National Plan for Preparedness and Response to a Possible Outbreak of Coronavirus Disease-2019 in the Democratic Republic of the Congo (National Plan). The plan was prepared by a National Coordination Commission that was put together during January 2020 in collaboration with the World Health Organization (WHO). The first chapter of the National Plan refers to the WHO's International Health Regulations of 2005 as a legal framework for its multisector response, through the Public Health Emergency Operations Centre (COUSP in its French acronym). Experience with such a centre had already been obtained during previous, and ongoing, Ebola epidemics in the country. From 1 February 2020 onwards, COUSP was active in the coordination, preparation and response to a possible epidemic.⁵¹ This was only two days after the WHO had declared the COVID-19 epidemic to be a public health emergency of international concern. Based on the National Plan, further provincial plans were developed, in which approaches were refined. These plans gradually became available in the following months.⁵² The National Plan elaborates on activities to be undertaken to realise seven main objectives. Some of these objectives are primarily epidemiological, or refer to the strengthening of the healthcare provision, but others target the population in more general terms, aimed for instance at: prevention and control of virus transmission in the community; promotion of community cohesion resilience and the reduction of stigmatization; provision of information in communities about the virus and risks; and development of interventions on the basis of community feedback to ensure engagement and appropriation of responses. The latter objectives and related strategies in particular underline the government's normative perspective that assumes that, if policy coincides with people's own moral orientations, they are more likely to comply. By informing people about the risks of the virus and by developing strategies based on input from communities, people are taken on board with the decision-making that leads to containment measures. This should ensure better compliance.

On 18 March 2020, President Tshisekedi proclaimed his Message to the Nation in which he asked the population to keep calm and “not to give in to panic, manipulation or misinformation, and to listen only to the advice of the scientists who inform our Government through the Ministry of Health, which recommends the right measures to adopt and the attitude to observe”.⁵³ In his message, the president announced that all flights from risk countries would be suspended and that strict border controls would be imposed. Hand-washing and temperature checks would be required at the border from then on.⁵⁴ This message also announced more far-reaching measures. Some days later, the message received further legal backing through Ordinance No 20/014 that declared a state of health emergency.⁵⁵ From then: it was prohibited to meet with more than 20 persons in public spaces;⁵⁶ schools and universities had to close for at least four weeks;⁵⁷ discotheques, bars, cafés and restaurants had to close, and it was prohibited to organize mourning ceremonies in halls, in public or at home;⁵⁸ and sports activities in stadia and other meeting places, as well as religious cults, were suspended until further notice.⁵⁹ In terms of content, the ordinance repeated most of the measures announced in the president's message, with the addition that the ordinance also explicitly stated that people should stay at home as much as possible and only travel “when strictly necessary for professional, family or health needs”.⁶⁰ Movement from the capital Kinshasa to other provinces was explicitly forbidden. In the ordinance, the government furthermore called upon the heads of national and provincial institutions to take appropriate measures to protect their staff and the general population from contamination. This was supposed to be done inter alia by raising awareness and ensuring that measures were applied,⁶¹ including the systematic sanitary control of all people entering the country or travelling to other provinces,⁶² and by quarantining suspected cases.⁶³ Finally, the government took responsibility to ensure that Kinshasa (which was to become isolated from the rest of the country) continued to be adequately supplied with consumer goods, and also with drinking water and electricity to ensure hygienic measures could be taken.⁶⁴ Remarkably, the ordinance made no reference to any sanctions or fines for those who violated the rules.

Additional measures were taken at a provincial level. One day before the promulgation of the national ordinance, the governor of South Kivu province (of which Bukavu is the capital) signed Provincial Order No 20/010/GP/SK on the Application of Decisions Relating to the Response to the Coronavirus Pandemic in South Kivu Province. This order defines, for instance, the number of passengers allowed aboard different types of public transport and the fines to be imposed for “recalcitrant” behaviour. These fines vary between 50,000 and 2,500,000 Congolese Francs (approximately GBP 18–930).⁶⁵ Shortly after this order, on 13 April 2020, the governor announced the obligation to wear face masks throughout the province, to be enforced by the police and army. In addition, the governor announced the obligation for people aged 60 and over to self-isolate.⁶⁶ To support the government's measures further, many state and non-state actors throughout the city of Bukavu engaged in awareness-raising campaigns: media (radio and television), health workers, civil society actors, churches, musicians and local authorities all took responsibility in this regard. This was in line with the national and provincial governmental plans, which all called for public engagement.⁶⁷ Local authorities also worked on the installation of more hand-washing stations throughout the city and tap water was available for free during this period, making it indeed easier for people to keep basic hygienic conditions.

The obligation to wear face masks was further supported from 28 April onwards through the governor's decision that anyone who violated the face mask rule would be fined 5,000 Congolese Francs (GBP 1.80), in line with the fines imposed elsewhere in the DRC. This decision was simply announced during a ceremony to celebrate the cure of the third, and by then last, officially confirmed case of COVID-19 in Bukavu.⁶⁸ In the weeks to follow, sewing workshops throughout the city quickly became specialized in the production of face masks, and the masks came to serve as a “laissez-passer” [informal transit permit] and a way to avoid police violence.⁶⁹ People became creative in complying with the face mask rule, not only in terms of the material from which their masks were made (often simply an old cloth or bra that was held in front of their mouth) but also in avoiding the payment of a fine. We noticed that most people became used to having a mask in their pockets, which they quickly put on as soon as a police officer came into view. Others would wear the mask below their chin simply to avoid a fine, but not as an effective measure. It suggests that compliance was mostly instrumental: out of fear of being sanctioned.

Messages from the government were not always very clear and sometimes even created confusion. The announcement by the provincial governor that the third and last COVID-positive person in the city was cured was quickly taken by people as a sign that the pandemic was over, and that measures could be loosened, whereas it would still be almost three months before the state of emergency was lifted.⁷⁰

When the state of emergency was lifted on 22 July 2020, restrictions gradually loosened. Commercial activities were officially allowed again, restaurants and bars could open, and public transport could start operating again.⁷¹ From 3 August 2020, primary and secondary schools and universities reopened, and church services were allowed again from 15 August. Harbours, airports and borders were opened as well. This was all supposed to be alongside the continued strict observance of measures that had been in place previously (ie face masks, hand-washing with disinfectant or soap at particular places, maintaining a physical distance of one meter, and thermo flash temperature-taking at the entrance to any office, church, store, etc).

At the time of data analysis and writing (October 2020), most measures had been loosened and, on the basis of official figures, the pandemic seemed to be somewhat controlled: on 13 October 2020, the total number of confirmed cases countrywide stood at 10,970, with a total of 298 deaths.⁷² South Kivu counted a total of 315 confirmed cases.⁷³ In the city, the general opinion was more and more that the disease does not exist, at least not in Bukavu. However, health providers and people who are better informed acknowledge its existence, also in the city. They continue their work of awareness-raising and of convincing people to comply with preventive and control measures as mentioned by the national and South Kivu provincial governments.⁷⁴ The fewer cases that are detected, the more difficult it will be to ensure people's compliance with strict measures. By 30 August 2021, the total number of confirmed cases countrywide stood at 54,508, with a total of 1,057 confirmed deaths.⁷⁵ In June 2021, strict preventive measures had been reinstated nationwide. These measures were extended on July 30 due to an ongoing third wave of infections.⁷⁶

ZOOMING IN: FINDINGS FROM BUKAVU

Before presenting the interview findings, this section presents some characteristics of the respondents. As mentioned above, they were all female. Their average age was 36.6 years, with eight respondents under 20, and 17 aged 60 and above (and thus supposed to be in full lockdown when the state of emergency was in force). 16 per cent of respondents had not gone to school at all, 22 per cent attended only primary school, against 51 per cent that went to (at least some classes of) secondary school. 7 per cent had attended university. 4 per cent preferred not to answer the question. Self-employment (petty trade, small businesses, farming) was the most common mode of employment. This applied to 44 per cent of respondents. About 37 per cent were unemployed. Fewer than 10 per cent had salaried positions and an even smaller number were still studying. Although the authors do not have figures on the respondents’ previous employment situation, they are confident, on the basis of previous research projects, that unemployment at the time of the survey was much higher than normal (when most respondents indicated that they were self-employed). This suggests that women have been hit hard by the consequences of the sanitary restrictions. More than half of the respondents lived in a household with four to six people and almost 30 per cent in a household of seven to ten people. More than 40 per cent of respondents originated from non-urban locations and had moved to the city in recent years, either because of the armed conflict, or for other reasons such as education or employment opportunities. The findings show furthermore that, when in need of healthcare, the respondents resorted to both “modern” and “traditional” healthcare, but in many cases also resorted to self-care through the use of herbs and plants. This often reflects a financial balancing of options, with public healthcare being unaffordable for many people.

What do women know about COVID-19?

Generally, respondents had good knowledge about COVID-19 symptoms and its modes of transmission. 5 per cent seemed to confuse COVID-19 with Ebola, as they mentioned nose and ear bleeding as symptoms, extreme levels of mortality and / or the very aggressive modes of transmission that are typically associated with Ebola. China, Europe or “the whites” were mentioned as sources of the disease, with some mentioning that the disease was “fabricated in a laboratory”, either in Europe or in China. Looking at the origin of the first cases of COVID-19 in the DRC, Europe is not an odd answer, as most early cases were connected to travel movements from or to Europe. A handful of respondents indicated that they doubted whether the virus really existed. People obtained knowledge about COVID-19 from March 2020 onwards, mostly through traditional media, such as radio and television, but also via social media. Frequently mentioned radio channels were local community radio stations (especially Radio Maendeleo), but also the national radio station RTNC. Those who mentioned television referred to the state channel. Churches and neighbourhood contacts were other important sources of information. Hardly any of the respondents had direct connections with people who had been diagnosed with the virus. Strikingly, all ten respondents who had heard about a COVID-19 case in their surrounding area referred to a fatal case, whereas nobody referred to somebody who had showed symptoms but recovered. This might be explained by a lack of testing and tracing. One can imagine though that a lack of tracing leads to the perception that COVID-19 is a deadly virus if only fatal cases are diagnosed.

Awareness of COVID-19 sanitary measures

The majority of respondents were afraid of becoming ill with the virus, mostly because of the lack of treatment and the mortality rate. However, 17 per cent indicated that they were not afraid. This was because they put trust in God, or because they did not believe that the virus exists and / or assumed they would not be targeted by it. One woman explained: “I am not afraid, because I am not part of the target group of the virus. I am neither old, nor rich”.⁷⁷

Generally, respondents were well aware of the main measures that were in place during the state of the health emergency. Two main channels of information about the measures emerge from the findings. Both church leaders and health workers were frequently mentioned and praised in this regard: “I am very well informed about the measures taken by the president through the awareness raising sessions that our pastor organised for the believers”, as a respondent explained. Health workers commonly used megaphones to inform people in the neighbourhood about COVID-19 and about preventive measures to take. This was well noted by many respondents, who expressed their appreciation and emphasized that the state should pay them proper salaries.

Asked about preventive measures that were taken by the government, most respondents mentioned regular washing of hands with soap or ashes, wearing a face mask outside the house, avoiding group meetings and physical distancing. The older respondents also mentioned the prohibition against leaving their house. The prohibition of church services and the closing of schools had made many people aware for the first time that measures against the virus were taken, as these measures impacted their everyday routines. Many women regretted the closing of churches for two main reasons. First, because they felt that, especially in these times, God would be able to help them. Secondly, because the church closure meant that the solidarity network that the church usually provides was interrupted.

Once the state of emergency ended, measures changed slightly, but respondents seemed to be less clear about these new measures: “I am not aware of what the president has decreed after the lockdown. I only notice that at the hospital [body] temperature is checked, but I don't see observance of other measures”, as a 20-year-old woman explained. Another respondent said: “[a]fter the lockdown, I have dropped all measures”.

Compliance

Many respondents felt the need to protect themselves and others and opined that the measures contributed to better protection. Usually, respondents did not distinguish between national and provincial measures: “I ensure the application of these measures, as it is a state law that protects us against this disease but also against cholera”, as one respondent put it. The more vulnerable respondents in particular, such as the handicapped and elderly, expressed taking care not to be infected. Most of them seemed to remain compliant, even after the strictest measures had been lifted. A 48-year-old woman for instance explained, “I put these measures into practice. Me and my husband, we are very exposed because of our HIV/AIDS. We also make sure our children apply all measures.” Another respondent, a 67-year-old woman, explained, “I haven't left home since the provincial governor forbade the elderly to leave their homes to avoid catching the virus. Since then my son doesn't accept that I leave home. Even though the churches have opened their doors I now stay at home, especially because many people don't respect the barrier measures [physical distancing] and I can easily be infected”.

Whereas a large group of respondents complied with the measures because they felt better protected, or because their pastor had told them to do so, others complied mostly out of fear of being sanctioned, but had less fear of becoming ill themselves: “I only respect the wearing of a face mask to avoid arrest”, a 29-year-old tailor told us. Others explained their compliance in similar terms, referring to the fear of being arrested, of having to pay a fine or of being harassed by the police. Some alluded to the death of a taxi-driver who was killed by a bullet fired by a policeman after a discussion about the driver not wearing a mask in his car. Although the provincial governor stated that the death was not related to the face mask, the story continued to circulate in the city, causing rumours and disagreement about the government's policy and police enforcement of it.⁷⁸ Generally, people seemed to be more fearful of being sanctioned in the central places of the city than in the periphery. The presence of the police at central places in the city, such as the market or important traffic hubs, is more palpable and people there run higher risks of being fined. One woman for instance explained, “I only respect the wearing of face masks when I go to the city [centre]. Other measures are not important. My husband runs a church in the corner of our neighbourhood. No-one can come and verify [whether we] respect the measures”.

State legitimacy played a more modest role in people's motivations to comply, but was not completely absent. A 29-year-old petty trader for instance explained, “[s]ince the head of state has lifted the state of emergency, I no longer follow these measures, I suppose that the disease does not exist since no-one in the neighbourhood has fallen ill to convince me of the presence of the disease”. Her words pointed at trust in the measures imposed by the head of state. At the same time, she also showed her fear of the sanctioning power of the state, when she continued her explanation saying, “[s]ometimes I respect the wearing of face masks to avoid paying the fines when I go into town”. As with the woman cited above, she resided in the periphery of the city where the police are not as present.

Others who referred to the need to respect the law related this more to a moral obligation to respect the law than to the legitimacy of the state. The church seems to play a role in this regard. “The logic in our church is to respect the law of the state. All these measures are followed and the believers are informed about them”, a 35-year-old unemployed woman explained. Another woman engaged in awareness raising herself and explained, “I raise awareness in our parish for all development activities. We have now been trained in the parish on how to accompany the population in the fight against this disease. And as soon as the head of state lifted the state of emergency, we made sure that the believers respected the [new] measures”.

Non-compliance

A small number of respondents (eight) admitted not being willing or able to comply with the measures imposed by the state. Sometimes this was because they felt it was only a means for the authorities to harass people and extort bribes, or because they did not see any use in it. “Death is certain anyway. Even if corona has come, we will die one day, even with another disease”, as one respondent put it. Again, God was mentioned a number of times by people to justify their behaviour. “There are no useful measures. Only God can save us from this disease and make an end to it”, as one young woman tellingly explained. Others referred to the African culture of close social contacts and the moral obligation to take care of sick people as an impediment to complying with physical distancing measures.

There seemed to be considerable confusion about the measures in place after the state of emergency had been lifted and a number of respondents indicated that, since the end of emergency, they were not aware of the rules, apart from the requirement to wear a face mask. A number of women assumed that the disease was over because churches were open again, or started to doubt the existence of COVID-19. Next, there was a small group of respondents who indicated practical difficulties in complying, such as difficulty breathing while doing physical work in the hills that characterize (especially the periphery of) the city. A handicapped woman stumbled upon difficulties when trying to comply with the measure to wash her hands at the entrance to her neighbourhood. She therefore avoided leaving her house and explained:

“Since the beginning of the confinement I have not left home, so I do not apply these measures. I am not even aware of the measures taken by the Head of State. Someone like you [nodding at the researcher] gave me 10 US dollars. This money helped me to start with a small income-generating activity and I am now selling ‘beignets’ [a fried pastry]. The taps [hand washing stations] placed everywhere are not even adapted to our physiological condition. It is difficult for me to stand up and reach the tap. And instead of being bothered by the policemen in town for [not] wearing a face mask, I prefer to stay at home.”

What do people think of the government at different levels?

In the interviews, the women were asked what they thought about the way in which national, provincial and municipal authorities had responded to the pandemic. As noted above, levels of trust in the government are generally low. In light of these findings, it is remarkable to note that many respondents expressed mixed feelings about the government rather than fully negative opinions. Many felt that they had been well protected by the early measures taken by the government, both at national and provincial levels. They felt that this had contributed to containing the pandemic and avoided the high numbers of infections that other countries had had. However, at the same time, many respondents added that they felt abandoned by the government because of the lack of any material support, such as livelihood assistance. The closing of borders and other in-country travel restrictions had greatly reduced the availability of food and increased prices, whereas many saw opportunities to make a living evaporate. The handicapped and elderly in particular indicated that they suffered and would have needed government support. For this, several respondents compared their own situation with the situation in neighbouring Rwanda, or with other countries where they had heard that the government provided support. A 43-year-old self-employed woman for instance said: “[t]he authorities did what they had to do, but they didn't do their duty to the population properly. They gave the order to the population and the population obeyed but they did not do anything in return like in other countries”.

The closing of the churches was seen as a measure that further exacerbated people's suffering. Many indicated that it was a wrong decision of the government to close churches as this also meant that people could no longer benefit from the aid that was provided through churches, or from jobs that are negotiated via the informal church network. In short, it reduced opportunities for solidarity. It is notable here that these respondents did not criticise the state authorities for not providing any support, but only reproached the authorities for cutting off the support that they would usually receive through the churches.

In reference to both the provincial and municipal authorities, many respondents highlighted the arbitrary arrests and harassment of people who had violated the obligation to wear a face mask. Instead of the fine of 5,000 Congolese Francs that was announced by the governor, some people noted, either from first or second-hand experience, having to pay a fine of up to 20,000 Congolese Francs instead. It was often felt that the money gathered this way was mostly lining the pockets of individual police officers instead of the state coffers. Most respondents did not make a clear distinction between provincial and municipal authorities, as they felt they were “all birds of the same feather”.

Health workers, whether or not employed by the state, were generally perceived very positively by the respondents. Many of them had noticed the presence of health workers with megaphones, leaflets and posters in their neighbourhood and this certainly contributed to awareness about both COVID-19 itself and the measures that were in place to avoid infection. It was felt that they needed encouragement and the proper payment of their salary. Only a small number of respondents were more reserved, had not noticed the presence of health workers, or even said that the health workers would have been chased away had they turned up in their neighbourhood, as people did not believe the disease existed.

WHAT DOES THE COVID-19 RESPONSE IN THE DRC TEACH US ABOUT COMPLIANCE AND LEGITIMACY?

The DRC government imposed a number of strict measures at an early stage of the pandemic. Looking at the way in which the measures were complied with, both instrumental and normative ways can be noted. It did not matter much to our respondents whether measures were imposed by the president or by the provincial governor. The findings show that deterrence played a major role in motivating Congolese women to comply with state-imposed sanitary measures to fight COVID-19. They especially sought to avoid police harassment. But this deterrence leads to what could be called “creative compliance”: people play with the rules and stretch them as much as possible at their convenience. This means that face masks for instance are worn, but not necessarily covering the nose and mouth, and that they are mostly worn at places where the risk of being sanctioned is high. Women know that the sanctioning police officers are not present everywhere and that one can often buy one's way out of paying a fine. The discretionary power to apply the law in a flexible manner is, in this case, not only in the hands of state officials, but also in the hands of the population, who bend the rules themselves, especially at the periphery of the city where the police presence is less visible.

From a normative perspective, the interviewed women complied because they feared falling ill and expected that the measures could prevent this. They had either learned about the modes of transmission through awareness raising campaigns in the media, in church, by health workers or via their social network. This underlines the importance of the provision of information to people in such a situation: not only about the measures themselves but also about the rationale behind these measures. A smaller number of respondents indicated that they complied with the measures simply because the state or church told them to do so. It is notable here that obeying the law “because it is the law” was in many cases induced by religious orientation: by church leaders telling people that they had to follow the law. Hence church leaders contribute indirectly to the legitimacy of the state and to levels of compliance.

Most of the respondents were fairly positive about the way in which the pandemic was contained and saw the measures taken by the government as important contributing factors. Despite these positive feelings about the success in containing the virus, people were also critical in noting a lack of state support for their livelihoods during the state of emergency. Whereas some felt that the state would have been responsible for the provision of support during the state of emergency, others reproached the state mostly for closing the churches and cutting them off from the aid that they would otherwise receive through the church or from fellow believers. It is telling that, in the Congolese context, people do not necessarily look to the state for the provision of livelihood assistance, but to non-state actors.

CONCLUSION AND OUTLOOK

This article has shown that compliance is shaped through a specific relationship that people have with the state and with the issue at hand, in this case COVID-19. This relationship is mediated by external actors, such as church leaders, health workers and the media, and has to be understood within the specific context in which factors such as individual vulnerability, persistent state fragility and very mundane practical considerations play a role. For a full understanding of compliance, a complete picture needs to be sketched to develop a context-specific comprehensive approach to contain an epidemic. What could be successful elements of such an approach? Four elements can be highlighted. First, the authors recommend that the “costs” of compliance for people be kept as low as possible. The less effort it takes for people to comply, the higher acceptance might become. For instance, if a handicapped person is not able to make use of the hand-washing station, it is not likely that she will use it. If an unemployed single mother is not able to buy a face mask, she will not make use of it. Material support to mitigate the impact of sanitary restrictions could be another way to improve people's perceptions about the state and subsequently make them more willing to comply. Secondly, the findings underline the important role that churches played, both in raising awareness about the virus and the measures in place, but also in convincing women to comply. Closing churches might therefore not have been effective, as it cut people off from church leaders and the solidarity network that the church represents to them. In this way, church leaders were less able to convey messages to their members. Thirdly, health workers, just like church leaders, are often closely connected to the communities in which they work and are therefore well positioned to convince people to comply. They are usually not taken first and foremost as representatives of a predatory state (as police officers are), but enjoy higher degrees of acceptance. Fourthly, the findings underline the importance of a comprehensive approach that not only targets sanitary conditions but also takes into account people's other basic needs. If people see their livelihood opportunities evaporate because of sanitary measures, they will need to be supported in their everyday survival. People might be positive about the government's health response, but if this leads to unaddressed economic hardships, the positive boost to state legitimacy that could be set forth by successful containment of COVID-19 is outweighed again by dissatisfaction about economic conditions.

What will happen in the future? The proof of the pudding is in the eating, and it needs to be seen what will happen once people increasingly start doubting the (continuing) existence and gravity of the virus in their country because of enduring low numbers of diagnosed cases. It would be interesting to carry out follow-up research to explore further the extent to which people continue to comply with measures and to dig more deeply into the question of state legitimacy in relation to the COVID policy. There are still interesting questions to explore in this regard, and the authors hope that the study presented in this article will serve as a useful starting point.