Title: Access to Health Care in the Democratic Republic of Congo
What support will the UK provide?
The UK will provide £184.9 GBP million over the next five years to strengthen basic health service provision in the Democratic Republic of Congo (DRC) in order to improve reproductive, maternal, neonatal and child health. The programme will build on DFID’s proven track record of improving access to health care and delivering health results in the DRC as a result of its existing Access to Health-care programme, which ends in December 2012 but will adopt a new approach of working more through Faith Based Networks to improve the sustainability of the programme. It will support at least 28 health zones (out of 515) in up to four of the eleven provinces in DRC, providing at least 2.7 million people with access to essential primary and secondary healthcare services. The design phase will start in Oct/November 2012 with implementation running for five years from early 2013 to March 2018.
DFID’s support will focus on engagement at three levels:
1. Engagement with non-state service providers to strengthen public sector health services DFID will continue to strengthen public sector provision of health services by working through non governmental organisations, civil society and faith based networks to implement this programme. In the DRC, faith based networks are very much part of public sector provision: about half of public sector facilities are run by faith based networks and about forty percent of health zone management teams are co-managed. Faith based networks are likely to continue to play a central role in public sector provision and we think that this will be a more sustainable way of supporting the government to deliver services whilst achieving value for money and managing fiduciary risk.
The programme will provide essential health care services for the whole population, whilst strengthening government health management teams. There will be a strong emphasis on ensuring that reproductive, maternal, neonatal and child health improves in the supported health zones. Implementing partners will be set clear targets on results in these areas. Dedicated reproductive health technical oversight will ensure that quality family planning and emergency Obstetric and Neonatal services (EmONC) services are available across the programme area. In each of the health zones supported, an implementing NGO/FBO will provide a package of support to health centres and hospitals consisting of essential medicines / supplies, infrastructure / equipment, training / supervision and the provision of salary incentives for staff. Funding will allow removal or heavy subsidy of user-fees for vulnerable groups (such as pregnant women and children under fives) by providing NGOs with the funds to pay salary incentives and procure drugs for health facilities they support, in order to reduce these fees. A budget will be available for solar energy for facilities to ensure that this programme is climate smart.
2. Engagement with communities and individuals Having a health system whose actors are more responsive and accountable to citizens is vital to ensuring that there is effective change in the DRC. DFID’s programme will have an emphasis on strengthening empowerment and accountability at a number of different levels, ensuring that citizens have a greater voice and that both service providers and the government are more accountable for delivering quality basic health services.
3. Engagement with the state.
DRC has been severely affected by prolonged conflict. Improving basic service delivery is a key entry point to strengthening the social contract in DRC i.e. assisting the state to be responsive to citizens needs. The state has a key role to play in health in the DRC. DFID will focus on strengthening the role of the Ministry of Health to act as an effective steward, provide an enabling environment for service delivery from a range of providers, set policy and manage health information. Part of this programme will provide capacity building to the Ministry of Health centrally to support them to strengthen these functions. Up to £5.2 GBP million will be available for a capacity building and technical assistance programme to support the Ministry of Health at central level. This will focus on key stewardship/policy functions with a strong emphasis on strengthening public financial management, for example in budget planning and execution and strengthening information systems.
Why DRC is a priority Building on its track record, DFID has the opportunity to deliver large scale health results in DRC as a result of both the severity of need and the size of the population. DRC has strong potential to deliver good health results as it has relatively strong human resources for health and a potentially strong underlying public health system (although in need of updating/strengthening). This programme will allow DFID to exert its comparative advantage in a country with a limited number of donors and a sector with decreasing external assistance
Approach DFID will contract an international organisation to lead the programme under a competitive tender process. The consortium lead will then partner with other Non-Governmental Organisations (NGOs) and/or Faith-Based Networks (FBNs) to form a consortium. The consortium lead will be responsible for managing the programme of support to both government and faith based network health facilities. The new programme will build upon DFID’s current Access to Healthcare programme but differ in a number of key ways:
Greater focus on strengthening empowerment and accountability at different levels -from the bottom up (in terms of citizens holding the MoH and service providers to account) and from the top down (in terms of the MoH holding service providers accountable and advocacy/parliamentary discourse). This would contribute to a more responsive government both centrally and de-centrally and potentially a stronger social contract.
Greater emphasis on working through Faith Based Networks to support service delivery as an entry point into strengthening public sector provision.
More support to strengthen the Ministry of Health. Government has a crucial role to play in stewardship, creating an enabling environment for service providers, policy setting and managing information. We would seek to strengthen these core functions by working to strengthen links between provincial, health zones and centres, provide technical assistance in key areas such as public financial management, budget planning/execution, strengthen the Ministry of Health’s ability to lobby stronger for resources and improve efficiency/oversight of salaries and strengthen use of information for oversight e.g. through the national health information system (SNIS).
Increased geographical coverage; DFID is now amongst the largest three donors in the health sector and can now increase considerably the number of zones we work in - from 20 to 30-40 out of 515 (depending on what the market can offer) by working in a more cost-effective approach.
Better value for money. DFID will advertise the envelope of funding and compare numbers of zones that lead agencies propose to support (i.e. cost per capita and planned package of support) against the expected results. We are confident that a change to a more sustainable approach is less costly and that market competition between agencies bidding for the consortium lead role will also maximise value for money.
Shift to a “managed programme” approach; an organisation as the consortium lead will oversee and manage other implementing partners according to a focused set of specifications determined by DFID. This arrangement has been used effectively by other donors in the DRC. It facilitates a more coherent standardised approach to support and provides a mechanism for closer quality assurance and cost monitoring.
Use evidence better by including an operational research/evaluation component in the programme to ensure that learning in the project can be effectively shared to implement change and be used for policy engagement.
Why is UK support required?
The DRC is the poorest country in the world according to the 2011 Human Development Index. Three in five of its 65 million people live on less than $1.25 (£0.80) per day. The DRC has some of the worst health indicators in Sub Saharan Africa. With one fifth of children born not reaching their first birthday, the DRC has the second highest level of child mortality. It also has the fourth highest level of maternal deaths, accounting for almost one in ten of all maternal deaths in Africa.
Access to health services is extremely limited. It is estimated that less than a quarter of citizens have access to healthcare across the country. Some of this lack of access is related to the barrier of cost since user fees are widespread.
DRC remains affected by conflict and fragility which continues to impact on the health system. This is a complex environment to work in with many challenges. But better access to basic health services and strengthened empowerment and accountability can have a positive impact on both recovery from conflict recovery and preventing further conflict.
Government financing to health care is extremely limited and as a result the Ministry of Health takes very limited responsibility for the provision of salaries and other resources required for public service provision. Per person per annum, the government contributes $2, donors $4 and households $6. User fees are the norm and act as a barrier to care. There is a strong link between subsidising care of vulnerable groups and delivering improved health outcomes. DFID will continue to ensure that user fees are not a barrier to care and will have a strong focus on operational research and evaluation so that findings can feed into policy discussions with the government and other donors.
DFID has invested heavily in capacity building of government facilities/health zone management teams through international NGOs. However the government is unlikely to be able to take over running these facilities in the medium term, particularly while salaries and drugs remain unfunded. Faith based networks are likely to remain key to sustainable service delivery, supporting half of public sector delivery and co-managing health zones. Continued support through these networks is required to improve access to healthcare and public sector provision as a whole. DRC has potentially strong human resources in health and a strong public health approach so there is great potential to deliver good health results.
In general, donor support remains fragmented in DRC and DFID will work more closely with other donors to ensure coherence of support nationally. DFID’s comprehensive approach has strong support from the Ministry of Health and is in line with DRC policy, and there is good evidence that it is more cost effective in terms of averting Disability Adjusted Life Years.
If DFID were not to continue support to healthcare it is expected that the results achieved by DFID over the past three years would be reversed, ultimately dropping back to the much lower levels of access to health services in the health zones concerned. This would contribute to compromising DRC’s progress towards Millennium Development Goals 4, 5 and 6. Unfortunately, the Government of DRC is not yet in a position to ensure that gains made under donor-funded interventions can be sustained.