Investing in Universal Health Coverage : Opportunities and Challenges for Health Financing in the Democratic Republic of Congo

The report contains eight chapters. Chapter one leads off with the main macroeconomic and fiscal determinants to understand the general health financing situation in DRC. Its sections one and two provide a brief overview of the country’s macroeconomic and fiscal environment. Section three sheds new light on decentralization, a core health issue, and focuses on the fiscal implications of decentralization. Section 4 offers a brief analysis of the management of public finance, a key element for the effectiveness and quality of expenditure, especially in health. Chapter two starts with a brief overview of the main objectives and analyzes its organization and governance, with a focus on health care delivery. Chapter three discusses the performance of the main health system’s outputs and outcomes. Section one analyzes major changes in health outcomes based on different household surveys. Section two addresses service coverage with a focus on mother and child services. Section three explores service quality issues. In a detailed analysis of health financing sources, Chapter four looks at changes in public, external, and private sources over 2008–2013 (section one). Section two analyzes the adequacy of government funding for health financing needs, and assesses the prospects for expanding fiscal space for health. Chapter five examines government funds mobilized for health, both allocated in the budget and executed (or actuals). Government resources for health are taken to mean all domestic financing sources allocated to the Ministry of Public Health and other health entities. Section one examines changes in the health budget envelope over 2007–2013, while section two focuses on actual spending. Section three analyzes government executed expenditure by nature and section four reviews trends and types of personnel expenditure, the largest share of government health expenditure. Chapter six focuses on health expenditure performance in the light of three main parameters: financial protection; equity; and efficiency. Section one analyzes financial protection using standard indicators (share of out-of-pocket payments, catastrophic expenditure, and impoverishing expenditure). Section two scrutinizes health outcomes and service use disparities and inequalities based on income, gender, and place of residence. The last section presents an overview of the efficiency of health expenditure in DRC, primarily in comparison to its peer countries. Chapter seven analyzes health financing from the point of view of the provinces, the new ‘entitled’ authorities for the health sector, drawing on a survey of financial and fiscal data from six provinces. Section one presents an overview of health financing flows after decentralization. Section two focuses on financing sources for the health sector at the provincial level, examining provincial government funds, external assistance, and central government transfers. The chapter ends with an analysis of the volume and type of decentralized government health expenditure. The report concludes in a brief chapter eight with a series of recommendations to improve short- and medium-term health sector financing and performance.