Democratic Republic of the Congo
CASE STUDY
Democratic Republic
of Congo
The Democratic Republic of the Congo (DRC) is home to vast natural resources, but it is also one of the world’s poorest countries, severely limiting its ability to improve health care systems. For years, the country endured armed conflict, political instability, and outbreaks
of hemorrhagic disease—most recently an Ebola virus epidemic that is the second-worst ever recorded worldwide.
The extreme and chronic challenges the DRC has faced in recent decades have made it difficult to increase domestic health care spending. This is why the Government of the DRC, in partnership with the GFF and key stakeholders, has prioritized the development of financing mechanisms to support the expansion of the package of essential reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N) activities laid out in the country’s investment case, the National Health Development Plan 2019–2022.
Strengthening the health system by improving the distribution and efficient use of financing in the DRC has already reduced costs of care for patients and quality and uptake of services. As these improvements continue to expand, attention will need to focus on stimulating demand for and access to services, while continuing to prioritize and maintain improvements in quality.
Trends in key RMNCAH-N indicators
(2007-2013/14)
- Maternal mortality ratio:Rose from 549 to 846 deaths per 100,000 live births
- Under-five mortality rate:Declined from 148 to 140 deaths per 1,000 live births
- Stunting prevalence among children under five:Declined from 45.5 percent to 42.7 percent
- Wasting prevalence among children under five:Declined from 10 percent to 7.9 percent
- Neonatal mortality rate:Declined from 42 to 28 deaths per 1,000 live births
Country Priorities: The National Health Development Plan
In 2018, the Ministry of Health reviewed the 2016–2020 National Health Development Plan (or PNDS, its acronym in French). The resulting document, the PNDS for 2019–2022, is the country’s investment case and includes a single set of costed, commonly agreed-upon priorities.1 Its central focus is the delivery of a primary health care services package that emphasizes improvements in reproductive, maternal, neonatal, child and adolescent health and nutrition (RMNCAH-N) using innovative financing mechanisms, including strategic purchasing, direct-facility financing, and single-contract pooled funding.
The GFF partnership, in collaboration with other key technical and financial stakeholders, has supported the implementation of the PNDS using these financial mechanisms, as well as provided broader technical assistance to enhance policy dialogue on domestic resource mobilization and health financing based on comprehensive resource mapping and program-based budgeting, among others.
Supporting the PNDS using innovative financing mechanisms
In 2015, the Health Systems Strengthening for Better Maternal and Child Health Results Program (or PDSS, its acronym in French) introduced a basic benefit package of cost-effective quality maternal, adolescent, and child health services for 21.8 million Congolese across 165 districts and 11 of the country's 26 provinces, covering close to a third of the population. This intervention uses the strategic purchasing of health services, which involves making payments to health facilities contingent on their achievement of outputs and results, in this case measured by the number of services provided and quality scores. Service packages are focused on maternal and child health preventive and promotive activities and infectious diseases such as tuberculosis, malaria, and HIV, all of this provided through extensive community-based activities in addition to access to curative care. Health facilities receive a quarterly advance equal to 60 percent of the previous quarter’s payment, with a second payment made after the quantity and quality of health services have been assessed and eventual sanctions to these payments have been applied. Out of the funding received, no more than 50 percent pertains to staff bonuses while at least 50 percent is used at the facility level for recurrent costs and strategies, as defined in their business plans to enhance quality and to reach health service utilization targets.
Direct-facility financing is another approach being used to deliver the essential health package, but it functions using an inputs-based approach, without the performance-based component. In other words, this form of financing is provided directly to the facilities, giving them autonomy and flexibility in how they use their funding so that it can be responsive to each facility’s needs and the disease burden of the respective area. The provision of this funding, however, is not dependent on the achievement of results.
Lastly, the single-contract mechanism is a contract between the Ministry of Health at the provincial level, the provincial health authority, and development partners. All financial resources for the given province are pooled to support one integrated health action plan, reducing the fragmentation of financing and promoting a more effective implementation and monitoring of the package of health services. The single contract was implemented beginning in 2017 across eight provinces (High Katanga, Kwilu, Kwango, Lualaba, Mai Ndombe, North Kivu, South Kivu, and South Ubangi).
Technical assistance to enhance policy dialogue around domestic resource mobilization and health financing
As part of the PNDS 2019-2022 development and with support from the Group of Donors for Health (or GIBS, its French acronym), the Ministry of Health conducted a detailed resource mapping that included all PNDS priorities mapped against the collective funds from domestic government budget sources and external funding partners (Figure 1). Although this exercise found that more than 10 external partners are aligned with and committed to financing the PNDS, a budgetary gap of 23 percent remains for fiscal year 2019.
Given the financial gap identified through the resource mapping exercise, the government recognizes that both an overall increase in domestic health funding and improved execution and efficiency of existing funds are needed to implement PNDS and achieve its objectives. In 2018, for example, less than 40 percent of the national health budget was spent, and many provinces spent only 20 percent of their budgeted resources, according to the Ministry of Health’s National Health Account. Therefore the government, with support from the World Bank and the GFF partnership, have introduced program-based budgeting, which establishes a more explicit connection between the budget’s purposes and its results, enabling better monitoring of increases in domestic and external resources to ensure that they match the commitments stated in the health financing strategy. Because it can also capture expenditures, program-based budgeting allows both leaders and civil society to more effectively monitor whether the commitments of government agencies and donors are invested in specific programs.
Figure 1
Mapping of resources contributing to the National Health Development Plan (PNDS) for the DRC, FY 2019
Results
The Government of the DRC has demonstrated progress in increasing its domestic health funding: the 2019 national health accounts show that the share of the national budget allocated to health increased from 7.0 percent to 8.5 percent between 2016 and 2018, putting the country on track to reach the target of a 10 percent allocation for health by 2022. Implementation is also underway of program-based budgeting, which maps PNDS priorities to individual budget line items in the health budget. Program-based budgeting has created a clear and direct connection between budget inputs and the expected performance outputs and outcomes.
Figure 2
Number of health facilities enrolled in the strategic purchasing mechanism in the DRC, by province, December 2017, January 2018, and December 2019
The strategic purchasing mechanism under the PDSS now reaches more than 2,800 facilities, including health centers and hospitals in 13 districts.
The scale-up of strategic purchasing, direct-facility financing, and single contract financing mechanisms has also been substantial in the last year. Figure 2 shows the progress in implementation of the strategic purchasing mechanism under the PDSS between 2017 and 2018. The PDSS has now been expanded to 1,963 facilities. The share of services delivered through this strategic purchasing mechanism has also doubled, on average, both for the number of women receiving one and four antenatal care visits (ANC1 and ANC4, respectively) and for assisted deliveries (Figure 3). Progress in scale-up is also being seen in the number of direct-facility financing facilities and single contracts signed. Since 2014, 843 facilities have been receiving direct-facility financing. Nine additional single contracts were signed in the fourth quarter of 2019, up from five single contracts signed in the first quarter of 2018.
Figure 3
Share of birth-related services financed through the strategic purchasing mechanism in the DRC, by Province, 2017–2019
Between 2017 and 2019, large increases were seen in the share of birth-related services delivered through the strategic purchasing mechanism.
Improvements in central- and provincial-level health financing investments and models have indicated significant shifts in the distribution of funding and services at the health facility level, which has translated to greater health service utilization and quality. A midline evaluation of the PDSS program provides insights into how health facility performance has improved and where gaps remain. Examining the impact of both direct-facility financing and results-based financing on the delivery of RMNCAH services, the evaluation found that significant progress has been made in changing how services are paid for: between 2017 and 2018, the share of health facility revenues derived from out-of-pocket payments declined from 70 percent to 54 percent, while third-party payments increased from 6 percent to 15 percent (Figure 4). Overall, patients are paying a substantially smaller share of the cost of health care at the facility.
The midline evaluation also shows that the observed financial shifts at the facility-level have led to positive impacts on the availability, quality, and patient use of RMNCAH and nutrition services (Table 1). For example, in facilities participating in the strategic purchasing mechanism, the average number of days during which antenatal care was provided increased. Provision of family planning services also increased, as did the availability of many essential core commodities, highlighting improvements in service delivery that may further promote utilization. For example, the use of family planning commodities rose, with a marked increase in long-acting injectibles and implantables.
Table 1
Use of antenatal care services and availability of related drugs and medical supplies
in the DRC, 2016 and 2018
Percentage of strategic purchasing facilities (PDSS) providing service
| Baseline (2016) | Midline (2018) | |
|---|---|---|
| Provides antenatal care (ANC) services | 99 | 100 |
| Days per week ANC provided | 1.24 days | 1.94 days |
| Always prescribes iron | 70 | 74 |
| Iron supplies available | 40 | 60 |
| Vitamin A supplies available | 19 | 58 |
| Always prescribe antimalarials | 76 | 82 |
| Malaria rapid tests supplies available | 56 | 82 |
| Always prescribe deworming pills | 65 | 72 |
| Provides antenatal care card | 96 | 94 |
| Provides family planning services | 32 | 74 |
| Contraceptive pills (progesterone) available | 2 | 22 |
| Contraceptive pills (combined) available | 10 | 41 |
| Injectables available | 14 | 57 |
| Implants available | 12 | 46 |
| Intrauterine device (IUD) supplies available | 13 | 22 |
Figure 4
Out-of-pocket and third-party payments as share of total health facility revenue, DRC, Q1 2017 to Q4 2018
With the introduction of new facility-level funding modalities (e.g., results-based financing) the share of revenue from out-of-pocket payments has declined and the share from third-party payments has risen.
Some of these improvements in service access and utilization in districts targeted by DRC’s many financing mechanisms have translated to regional-level results. From 2017 to the end of 2018, data from the regions in which these mechanisms are implemented shows increases in the number of women seen for ANC 1, ANC 4, assisted delivery, and postnatal care (Figure 5). In January 2017, fewer than 300,000 women received ANC1 services; this figure rose to 310,000 women by the end of 2018. ANC4 showed similar increases. About 50,000 additional women had assisted deliveries, and 60,000 additional women sought postnatal care.
Figure 5
Investments in service delivery and access in targeted regions have begun to show results at the regional level
Use of ante-natal care, assisted delivery, and post-natal care services in regions participating in innovative financing mechanisms in the Democratic Republic of Congo, 2017–18.
System strengthening investments, such as the use of varied financing mechanisms to health facilities, have demonstrated trickle-down effects on service access, quality, and utilization that are extremely promising in the DRC. The challenge that remains and will require continued effort looking ahead lies in the continued expansion of these models, in a way that retains quality but also that stimulates demand, especially among the country’s most vulnerable populations.