2014年-世界发展银行全球_Investing_in_Universal_Health_Coverage___Opportunities_and_Challenges_for_Health_Financing_in_the_Democratic_Republic_of_Congo_80页_7mb

Summary of the 2014 Health Public Expenditure Review in the Democratic Republic of Congo

Core Content

This report, Investing in Universal Health Coverage: Opportunities and Challenges for Health Financing in the Democratic Republic of Congo, provides a comprehensive analysis of the health financing landscape in the DRC. It outlines the current state of the health system, the macroeconomic and fiscal environment, and the challenges and opportunities in expanding health coverage and financial protection.

Main Views and Key Information

1. Background and Policy Context

• The DRC is preparing to adopt a historic bill on Universal Health Coverage (UHC).
• Despite some progress in health outcomes, only 3/5 of children with respiratory infections, diarrhea, and fever receive treatment.
• Health financing is currently dominated by international aid and out-of-pocket payments, with the government contributing less than 20%.
• To achieve UHC, the government needs to significantly increase its health expenditure, ideally more than USD 1 per capita annually.

2. Macroeconomic and Fiscal Environment

• The DRC experienced strong economic growth (7.4% annually, 2009–2013), primarily driven by the mining sector.
• However, government revenue collection has not kept pace with this growth, and domestic revenues have stagnated at 13% of GDP due to low indirect tax collection and natural resource sector underperformance.
• Health expenditure as a percentage of GDP has declined, from 4.6% in 2008 to 3.8% in 2011–2012, raising concerns about the ability to fund UHC.
• The DRC has considerable fiscal potential to increase domestic revenues, potentially reaching 8 percentage points of GDP through improved tax collection, especially in the mining sector.

3. Health System Organization and Resources

• The health system is fragmented and underdeveloped, with poor infrastructure and equipment availability.
• Primary health care coverage has improved, but referral systems are lacking, and less than 30% of health facilities are operational.
• Human resources for health (HRH) are limited, especially in rural areas. Physicians and nurses are concentrated in urban centers, with Kinshasa having 1.3 physicians per 10,000 inhabitants, compared to less than 0.7 in other provinces.
• Pharmaceutical availability is a major challenge, with essential drugs often in short supply.

4. Health System Performance

• Some progress has been made, particularly in maternal and child health:
  • Antenatal care coverage increased from 68% to 88% (2001–2014).
  • Skilled birth attendance rose from 61% to 80%.
  • Use of insecticide-treated nets increased significantly, from 6% to 56%.
• However, child mortality and malnutrition remain high:
  • Child mortality fell from 90 per 1,000 live births (1997–2007) to 58 per 1,000 (2013–2014).
  • 43% of children are still malnourished, with nearly half suffering from severe malnutrition.
• Maternal mortality has declined from over 1,000 per 100,000 births to 846 per 100,000 births (2007–2014), but remains higher than the regional average.

5. Health Financing Sources and Trends

• Health financing is highly dependent on external aid and out-of-pocket payments:
  • External assistance accounts for ~40% of total health financing.
  • Out-of-pocket payments account for ~90% of household health expenditure.
  • The government's share is minimal, at ~15% of total health expenditure, and ~4% of the central government budget.
• Health spending per capita is USD 13, which is less than one-tenth of the average for the rest of Sub-Saharan Africa.
• Decentralization has increased earmarked transfers to provinces, but execution of these transfers remains poor.
• Provincial health budgets are small, with ~4% of provincial resources allocated to health, and only 10 cents per capita from local revenues.

6. Health Expenditure Performance

• Financial protection is lacking, with >80% of health spending coming from out-of-pocket payments.
• Equity concerns are evident, as the poorest spend more of their income on health and are more vulnerable to catastrophic health expenditure.
• Efficiency is low, with only 40 cents spent per dollar allocated to health, and 20 cents targeted at priority interventions.
• Health expenditure is highly skewed toward hospitals, which are used more by the richest quintile, while primary care services receive minimal support.
• Provincial health expenditure is highly imbalanced, with Kinshasa receiving 5 times more than the rest of the country.

7. Opportunities and Challenges

• Key opportunities include:
  • Increasing domestic revenue collection (especially from the mining sector) to generate more than 8% of GDP.
  • Expanding health budget allocation to ~8% of government spending.
  • Implementing decentralization reforms to improve provincial resource management.
  • Enhancing service quality and coverage, especially in primary and community care.
• Key challenges include:
  • Poor financial protection and high out-of-pocket costs.
  • Inequitable access to health services, especially for the poorest and rural populations.
  • Low efficiency in health spending, with wasteful payroll increases and limited capital investment.
  • Fragmented and under-resourced health system.

8. Policy Recommendations

• Accelerate Public Finance Management (PFM) reforms to improve budget execution and efficiency.
• Refocus on primary and community health care to enhance coverage and efficiency.
• Improve tax collection systems, particularly in the mining sector, to increase domestic resources.
• Explore provincial resource pooling to enhance equity and efficiency in health financing.
• Implement quality care packages and reform provider payment systems to improve service delivery.
• Consider nationwide prepayment mechanisms, such as mandatory health insurance, in the long term.
• Ensure that fiscal and budgetary capacities at the decentralized level are strengthened to support health financing.

Conclusion

The report highlights the need for a comprehensive and sustainable approach to health financing in the DRC, emphasizing the importance of increasing domestic revenue, improving PFM, and refocusing on primary care. It also underscores the potential of decentralization to improve resource allocation and governance, but stresses the need for effective implementation and greater fiscal space to achieve UHC. The health system must be reformed to ensure equity, efficiency, and financial protection for all citizens, especially the poorest and most vulnerable.