Building on recent progress, the Democratic Republic of Congo (DRC) has continued to invest in the health and nutrition of women, children and adolescents. With support from the Global Financing Facility (GFF), the government has not only further increased domestic resources for health but also strengthened the efficiency of existing resources to support the most pressing health priorities. This has helped to expand quality health services in the country’s worst affected areas while protecting households from financial hardship. As a result, more women and children are visiting health facilities and benefiting from assisted births and other lifesaving services.
Keeping the Momentum
The Democratic Republic of Congo (DRC) has endured chronic political instability and armed conflict, as well as multiple Ebola outbreaks over the past couple of years that have put additional pressures on already strained health systems. Yet, as a result of the government’s efforts and commitment, deaths of children under age 5 dropped by one-third from 2014 to 2017 and the teenage pregnancy rate fell by one-fifth. However, about 42 percent of children are still stunted as a result of chronic malnutrition.
The exceptional challenges in DRC have historically made it difficult to increase domestic spending on health. Making it even more important that existing resources are efficiently used and are allocated for high priority needs. The government, with support from the GFF, developed a national plan to prioritize key health system and financing reforms to accelerate progress in health and nutrition outcomes across the country’s 26 provinces. The 2019-2022 plan also set a goal to increase the country’s budget allocation to health percent from 7.6 to 8.6 percent and budget efficiency to 90 percent. The plan also seeks to lessen the financial burden of health care costs to families (catastrophic health expenditures) from 4 to 3 percent.
Progress in Health Financing Reforms
The GFF is supporting DRC’s national plan with a total of US$60 million in grant financing linked to US$340 million support from the World Bank’s International Development Association (IDA). Other GFF partners and donors, including USAID, Gavi and the Global Fund, are also financing the plan’s priorities. Two years into implementation, the plan has successfully guided policy makers through difficult budget allocation choices and health financing reforms to achieve results in several areas:
- Greater efficiency, transparency and more equitable allocation of existing national health budget resources: The GFF’s support to the Ministry of Health has helped the government transition to program-based budgeting, a process that makes spending more transparent and helps ensure it goes towards priorities specified in the investment case. In 2019, the national budget execution rate – the measure of whether the budget is being spent as it was allocated -- was operating at only half the efficiency of the donor budget (which stood at almost 100 percent). There were also major inequalities in resource allocation among provinces, resulting in weak health outcomes. Based on the new budget process, the governor of Maniema province, one of DRC’s poorest provinces, pledged more resources and more efficient spending of existing resources for health. This information has also enabled the Ministry of Health to advocate fora larger share of the national budget for health.
- More sustainable reforms: The transition to a more transparent, efficient and result-oriented budgeting process is enabling the government to generate more reliable, annual data to track spending and results and ensure sustainable financing for essential health services. The government also established a new fiduciary unit to manage budget flows and improve resource use both in the provinces and at national level.
- Increase in domestic resources for health: The GFF supported the Ministry of Health to map resources and track expenses, an exercise that revealed sizeable funding gaps to implement the plan’s priorities. This was a catalyst to convince the government to increase domestic resources for health from 7 to 8.5 percent between 2017-2018 and to a further 10.7 percent in 2019, exceeding the plan’s target of 8.6 percent by 2022. The government has also tripled its spending on vaccinations from US$4.4 million to US$9 million in 2019 and subsequently to US$16.4 million in the first half of 2020.
- Decrease out-of-pocket expenses: With GFF support, the government designed and rolled out contracts for the strategic purchasing of services in 11 provinces. Making payments to health providers contingent upon their performance has helped expand quality services while reducing the economic burden on households. Other GFF partners, such as the European Union, are also supporting strategic purchasing reforms in the country.
Expanded Access to Health Services
Improving the allocation and efficient use of health spending in the DRC has already reduced the cost of care for many patients, strengthened service quality, and increased the uptake of services through the rollout of performance-based financing in 11 provinces amongst other interventions. The World Bank and the GFF are contributing to better outcomes by focusing their investment on those 11 provinces.
Increased access to primary health facilities
- The average number of outpatient admissions in facilities where payments were linked to performance rose from 59 to 67 percent between 2018 and the first quarter of 2020. The increase in admissions ranged among provinces, from 21 percent in Haut Katanga to 84 percent in Sud Ubangi.
Improved maternal and child health care
- Between 2017 and 2019, across the country 18 percent more women attended their first antenatal visit and 30 percent more women attended at least four antenatal visits. Postnatal care almost doubled from 30 to 56 percent.
- Three percent more women gave birth with the help of a skilled provider, bringing coverage to 91 percent in 24 out of 26 provinces in 2019.
- The malaria mortality rate declined by 58 percent nationally to reach 0.04 percent in 2019. Declines were reported in 24 of the 26 provinces, with the only substantive rise occurring in Sankuru Province, from 0.17 to 0.24 percent.