The Democratic Republic of Congo (DRC) aims to achieve Universal Health Coverage (UHC) by 2030, but faces challenges in health budget execution and allocation. Key points include:
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Health Financing Context:
- Health spending is predominantly financed by households (45%) and donors (44%), with government financing accounting for only 10-16%.
- Total health expenditure ranges from US$19 to US$222 per capita (2013-2019), far below the UHC target of US$86 per capita.
- While health sector budget allocation has increased, the growth is driven by donor resources, and public resource allocation remains below the Abuja Declaration target of 15%.
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Budget Execution in Health:
- The overall health budget execution rate is modest, averaging 47.6% of initial budget allocations (2016-2020).
- Execution rates vary significantly by category: health worker payments average 103%, while other operational spending (excluding workers) averages 48%.
- Capital spending execution is low, with an average of 19% for internally financed capital and 38% for externally financed capital.
- Budget controls are largely bypassed, with many expenditures not included in the voted budget and planned activities often unexecuted.
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Public Financial Management Controls for Health Spending:
- Ex-ante controls are managed by the Ministry of Budget, Ministry of Finance, and Central Bank, while ex-post controls are handled by the General Inspectorate of Finance, Court of Auditors, and Parliament.
- Adequacy issues exist, particularly in wage and salary controls, with challenges in real-time assessments due to lack of integration between civil service and budget software.
- Payment arrears are substantial (US$181 million as of January 2021) but not effectively monitored, with delays impacting procurement costs.
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Good Practices and Bottlenecks:
- Good practices include the establishment of the Department of Administration and Finance within the Ministry of Health and the creation of a Health-Budget-Finance Committee.
- Program budgets have been introduced to improve allocative efficiency, though execution processes have not yet fully utilized this format.
- Bottlenecks include over-estimation of budget revenue, highly centralized execution processes, dominance of health worker payments in budget allocations, disregard for budget management rules, and cumbersome procurement and expenditure procedures.
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External and Internal Root Causes:
- External causes include systematic over-estimation of national revenue and the highly centralized nature of budget execution.
- Internal causes include inadequate programming of budget priorities, misalignment between health planning and budget cycles, and lack of consideration for execution performance in budget allocations.
