CASE STUDY
Democratic Republic of Congo
In the Democratic Republic of Congo (DRC), the GFF was launched in April 2015. The government put in place a GFF platform that brought together the key government health stakeholders, other line ministries, civil society representatives, and development partners. The GFF platform took the lead in developing the country’s RMNCAH-N investment case, which prioritizes the interventions laid out in the National Strategic Development Plan 2016- 2020.
The Ministry of Health, with representatives from civil society organizations, focused on defining RMNCAH-N priorities; UNICEF conducted a health system bottleneck analysis; WHO provided support in costing the investment case; and the GFF Secretariat helped with the resource mapping exercise with the support of the government and several donors.
Scaling Up Essential Services
The investment case has identified 12 priorities with a goal of reducing maternal mortality from 890 to 800 per 100,000 and child mortality from 119 to 88 per 1,000, over a period of five years, in 14 priority provinces.1 Among the 12 priorities, Priority 1 is to scale up an essential package of high-impact, cost-effective RMNCAH-N services. This priority is the cornerstone of the investment case and accounts for three-quarters of its total budget. The Ministry of Health, the World Bank, the GFF, the Global Fund, Gavi, UNICEF, UNFPA, and USAID have aligned their technical and financial resources in support of the implementation of the identified priority areas.
Early progress noted
During 2017, the number of women and children in the 14 provinces using the essential package of health services under Priority 1 has increased substantially. Looking at utilization data from 2017, in December 2017 there were 39,000 more children vaccinated with the BCG vaccine and 25,000 more children vaccinated with three doses of the DTP/Hepatitis B/Hib pentavalent vaccine compared to January 2017. Similarly, there were 15,000 more assisted deliveries and about 4,000 more women attended four antenatal counseling sessions in December 2017 compared to January 2017 (Figure 3).
Put differently, from January to December 2017, the number of children vaccinated with BCG vaccine increased by about 35 percent, the number of children vaccinated with the DTP/Hepatitis B/Hib vaccine by 25 percent, the number of assisted deliveries by 14 percent, and the number of antenatal care consultations by 6 percent.
FIGURE 3
Provision of Key Maternal and Child Health Services in the 14 Targeted Provinces, DRC, 2017
Performance-based Financing
The investment case has served as a catalyst for health financing reforms. One of these was the introduction of strategic purchasing, that is, paying health facilities based on their performance and providing financial incentives for increasing the quantity and quality of the essential maternal and child services provided (IC Priority 5). The strategic purchasing program is supported through pooled financing from the Norwegian Agency for Development Cooperation (NORAD), the Government of Canada, the Bill & Melinda Gates Foundation, USAID, the Global Fund, and the World Bank. It is supplemented by complementary activities and interventions financed by a number of other partners.
Early progress noted
In January 2018 about 2,940 out of 17,000 health facilities in the DRC were participating in the program. The rationalization of the payment system and the introduction of strategic purchasing have resulted in additional increases in the number of children and women receiving services, above and beyond the positive trends in the prioritized provinces (Figure 4).
Over the 12 months of 2017, when compared with health facilities that did not participate in the strategic purchasing program, on average each participating facility added 16 more antenatal care consultations, 36 more assisted deliveries, and 31 more children vaccinated with BCG and 32 more with the third and final dose of the DTP/Hepatitis B/Hib pentavalent vaccine 2. Put differently, over the 12 months of 2017, strategic purchasing has increased the levels of BCG vaccination by 11 percent, DTP/ Hepatitis B/Hib vaccination by 13 percent, antenatal care consultations by 14 percent, and assisted delivery by 19 percent, on average, in facilities that participate in the program.
At the national level, thanks to strategic purchasing, 8,500 more children were vaccinated with the BCG vaccine, 8,700 more children were vaccinated with the DTP/Hepatitis B/Hib vaccine, there were 10,000 more assisted deliveries, and about 4,000 more women received three antenatal care consultations3 in December 2017 than in January of the same year.
FIGURE 4
Provision of Key Maternal and Child Health Services in the 14 Targeted Provinces, DRC, 2017
Average number of assisted deliveries in primary health care facilities in DRC, 2017
Average number of pregnant women receiving 4th ANC in the 36 week of pregnancy in primary health care facilities in DRC, 2017
Average number of children vaccinated with the BCG vaccine in DRC, 2017
Average number of children vaccinated for DTP/HepBN/HiB (3 doses) in DRC, 2017
General Trend in Facilities Not Participating in Strategic Purchasing
Counterfactual Trend in Strategic Purchasing Facilities (what would have happened in strategic purchasing facilities if they did not participate in the program and followed the general trend instead)
General Trend in Facilities Not Participating in Strategic Purchasing Trend in Facilities Participating in Strategic Purchasing
Net Gains in Services Provided Thanks to Strategic Purchasing (above the counterfactual trend)
Developing Accurate, Timely Data
The investment case stresses the need to develop accurate, complete, and timely data for effective management of the health sector and to ensure quality and efficiency of service delivery. It includes strengthening the health information system as Priority 11. The investment case supports the expansion of the health management information system (système d’information sanitaire or SNIS) and its electronic DHIS2 platform with a focus on the provincial and health zone levels.
Early progress noted
To date, financial resources for the strengthening of the SNIS have been allocated by the World Bank with additional support from USAID, Gavi, the Global Fund, and the United Kingdom’s Department for International Development (DFID). These investments have resulted in tangible improvements in data quality. During 2017, the number of health centers with missing monthly reports on the key RMNCAH-N services prioritized in the investment case has declined by 6.2 percent for the DTP/ Hepatitis B/Hib pentavalent vaccine, 7.1 percent for the BCG vaccine, 10 percent for four antenatal care visits, and 16 percent for assisted deliveries.
Streamlining Financing
To further improve the alignment of domestic and external resources and achieve more effective coverage of services at a decentralized level, the investment case has scaled up an existing mechanism called the “single contract” or contrat unique (CU) (Priority 9).
The contrat unique is a contract between the Ministry of Health at the provincial level (contracting authority), the provincial health authority (providers of health services), and development partners. The objective of the contrat unique is to pool virtually all financial resources to support a single, integrated provincial health action plan, thereby reducing the fragmentation of financing and ensuring that the RMNCAH-N package of services is properly implemented and monitored. The contrat unique is intended to strengthen the fiduciary capacity of the provincial health administration by using a single accounting system, and it is a powerful mechanism for tracking government and development partners’ commitment and expenditures with respect to the provincial workplans (Figure 5.)
Early progress noted
The contrat unique started in 2017 in eight provinces: Nord Kivu, Sud Kivu, Kwilu, Kwango, Mai Ndombe, Sud Ubangi, Lualaba, and Haut Katanga. Regular independent evaluations of its implementation, which focus on mutual accountability of all stakeholders, have begun and are showing promising results. For example, the execution of RMNCAH-N planned activities in Nord Kivu increased from 54 percent to 68 percent between the first and second trimester of 2017.
Disbursement on financial commitments from donors and the central government has improved with time, going beyond 50 percent in several provinces. Further analytical work on domestic resource mobilization is to be conducted to examine potential mechanisms for increasing domestic funding of health services at the provincial level. This is necessary because the financial commitments from provincial health authorities to date remain low as part of the single contract. This analytical work funded by Gavi, the GFF, and the World Bank is all part of the Health Financing Strategy. Given poor budget absorption of existing resources (58 percent), the Health Financing Strategy is focusing its domestic resource mobilization agenda over the short-term on improving the efficiency of existing resources through single-contract, strategic purchasing, public financial management, and human resource reforms. Over the mid- to long-term, the Ministry of Health is to improve the share of the national budget allocated to health (5 percent). The planned study by Gavi, the GFF, and the World Bank will examine the potential and feasibility of earmarked taxes, tax collection reforms, and better prioritization of health at both provincial and national levels, laying out key reforms for the mid- to long-term to leverage more resource for the health sector.
We are well taken care of and the nurses are always welcoming.
– Marie Kumba, Holy Spirit Health Center. She came to the center for all of her prenatal consultations, where she also received a bed net provided by Sanru, an NGO that delivers Global Fund bed nets
FIGURE 5
Using a Single-Contract Approach to Better Align Financing and Improve Performance
Traditional Approach
vs
Single Contract
CASE STUDY
The Republic of Cameroon
Despite its lower-middle-income status, Cameroon was recently ranked 153rd out of the 188 countries tracked in the Human Development Index (HDI 2014) and, indeed, it is one of a group of countries whose HDI scores have declined in the past two decades. Contributing to this HDI deterioration is slow progress on key health outcomes.
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Nigeria
Nigeria has always been committed to the principles of universal health coverage and has adopted policy documents and legislation to that effect. However, indicators of Nigeria’s health outcomes and actual coverage of basic health services show under performance, both in absolute terms and relative to other countries at similar levels of economic development. Key drivers of underperformance include a health system unable to ensure universal coverage of primary health care services and weak accountability for results. The health sector has long been underfunded, and its structural and institutional frameworks have placed concurrent responsibilities on all three tiers of government (federal, state, and local) without any mechanism for intergovernmental accountability.
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United Republic of Tanzania
Between 2010 and 2015, Tanzania saw notable improvements in life expectancy (from 61.6 to 64.9 years), infant mortality rate (from 51 to 43 per 1,000 live births), under-five mortality rate (from 81 to 67 per 1,000 live births), and under-five stunting prevalence (from 42 to 34.4 percent). However, during this period the country’s maternal mortality rate increased from 454 to 556, and its total fertility rate remained stubbornly high at 5.2 (as of 2015). The increase in maternal mortality elevated maternal health to a national priority. To address this and other lingering challenges in RMNCAH-N, in 2015 Tanzania began implementing its RMNCAH-N investment case, known as One Plan II.
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