DRC has some of the highest maternal and child mortality ratios in the world, and chronic malnutrition. Households bear 40% of total health expenditures and public spending on health is inefficiently allocated. At 846 deaths per 100,000 live births in 2014, Democratic Republic of Congo has one of the highest maternal mortality ratios in the world. Women have an average of 6.6 children, and 42 percent of women in the poorest wealth quintiles, aged 15-19 years, are mothers or pregnant with their first child. The contraceptive prevalence rate is 8 percent and population growth is 3 percent. For every 1,000 children born, 58 die before their first birthday and 105 die within the first five years of life. Chronic malnutrition affects 43 percent of children under five, one of the worst rates in the world.
These poor health outcomes are linked to low levels of effective coverage of high-impact reproductive, maternal, newborn, child and adolescent health (RMNCAH) services, particularly low quality antenatal and delivery care and low capacity for emergency obstetric care.
In 2015, per capita health spending was US$ 22 in the Democratic Republic of Congo, one-sixth of the average in Sub-Saharan Africa and one-fourth of the amount necessary to provide basic health services to the population (McIntryre and Meheus, 2014). Households bear 40 percentof total health expenditures, 93 percent of which is made of out-of-pocket expenditures while donors are another key driver of total health expenditures, funding 40 percent of it. Public health spending is only 12 percent of the total health expenditure and is inefficiently allocated to population health needs.
THE GFF IN THE DEMOCRATIC REPUBLIC OF CONGO
The GFF was launched in April 2015 after which the Government of the Democratic Republic of Congo put in place a GFF platform that grouped together health stakeholders as well as other line ministries, representatives from civil society, and technical and financial partners. The GFF platform took the lead in developing the country’s investment case which prioritizes even further the interventions laid out in the National Strategic Development Plan 2016-2020.
The Ministry of Health, with representatives from the civil society, focused on defining RMNCAH priorities; UNICEF conducted a health system bottleneck analysis; the World Health Organization provided support in costing the investment framework; and the GFF secretariat helped with the resource mapping exercise. In the future, the GFF platform will be tasked to monitor the implementation of the investment casein the 14 prioritized provinces.
HIGHLIGHTS OF THE INVESTMENT CASE IN THE DEMOCRATIC REPUBLIC OF CONGO
Aligned with the National Strategic Development Plan 2016-2020, the investment framework for the Democratic Republic of Congo, focuses on the expansion of an integrated RMNCAH essential package of services, the strengthening of supply chains for essential drugsand vaccines, the improvement of public financing management, the strengthening of human resources, and the establishment of a functional civil registration system. Strategic purchasing through performance-based financing has been adopted as one of the key reform agenda to address government priorities to improve the governance and management of the health system and to deliver the RMNACH integrated essential package of services. The government has prioritized 14 provinces (out of 26) with the least performing health and socioeconomic
indicators as key targeted regions to align and harmonize domestic and external support.
Innovative highlights of the investment case include:
- Family kits to facilitate safe home-based management of diarrhea and childbirth;
- Medical and psychosocial services to support individuals affected by sexual- and gender-based violence;
- Community spaces for peer education on contraceptive use among adolescents;
- Launch of a nationwide community-led water, sanitation, and hygiene program;
- Address chronic malnutrition by scaling up the Community Nutrition-Based Approach (Nutrition à Assise Communautaire-NAC) in the 14 provinces and incentivize community groups to provide more counselling on nutrition as part of the RBF. The goal of NAC is to educate communities on the problems of chronic malnutrition and their multi-sectoral solutions;
- Engage with the private sector as a key actor for improving system performance and achieve results.
FIGURE 1. COMPLEMENTARY FUNDING OF THE INVESTMENT CASE
The investment case aims to expand population coverage to an integrated RMNCAH package from 27 percent in 2017 to almost 40 percent in 2021 in the 14 provinces, which will contribute to reduce the maternal mortalityratio by an average of 7 percent and the under-five child
mortality by an average of 17 percent1.
Currently, the government, the private sector and technical and financial partners cover 68 percent of the investment framework’s budget, representing 1,801,228,420 US$ over five years (8,94 US$ per capita per year). This implies a financial need of 32 percent, representing US$844 million over five years (US$4,14 per capita per year) for the 14 provinces prioritized in the investment case.
KEY HEALTH FINANCING PRIORITIES
The GFF is supporting the government’s efforts to enhance domestic resource mobilization in health by exploring options both at the provincial and national levels, improve the efficiency of domestic and international financing focusing on priorities identified in the investment framework, including donor mapping, performance-based financing, community engagement, and implementation of reforms the single contract to increase resources to like enhancing coverage and quality of essential health services. These efforts are reflected in
the Health Financing Strategy developed by the Ministry of Health that outlines reforms to improve public financial management of budgeted health expenditures and improve tax collection and administration thus, increasing fiscal space available for health and other sectors. To
increase financial protection, the health financing strategy underscores the need to reduce fragmentation in the health insurance system by pooling health insurance mechanisms from the private and public sector, subsidizing the poor, and expanding community-based health insurance to target the informal sector.
Efficiency is at the core of the investment framework in the Democratic Republic of Congo, which focuses on resource pooling at the provincial level by expanding its experience with the Contrat Unique (single contract). The objective of this reform, at the decentralized level, is to have one budgeted plan of activities in the provincial health administration that is financed through the pooling of domestic and external funds. This reform addresses fragmentation in funding and service delivery—a major driver of inefficiencies—with the aim of strengthening planningand reducing administrative and management costs. The single contract puts in place a performance framework to assess the performance of the provincial health directorate. Although the single contract was created before GFF, it is being scaled up as part of the investment framework. Along with this single contract, several reforms, such as those aimed at reducing the number of parallel supply chains delivering drugs to the same facility and decentralizing human resource management, are under implementation.
The GFF process has changed the nature of the dialogue between the Ministries of Health and Finance, moving from a focus on clinical issues and disease burden to a focus on results and returns on investments for health. The investment case concentrates on scaling-up quality RMNCAH-N services with an emphasis on nutrition, family planning and health system strengthening.
FIGURE 2. THE 14 PROVINCES INCLUDED IN THE INVESTMENT FRAMEWORK