The Role of the Private Sectorin Improving the Performanceof the Health System in  emocratic Republic of Congo the D The Role of the Private Sectorin Improving the Performanceof the Health System in Democratic Republic of Congo the   i ii T H E ROL E OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCR ATIC RE PUBL I C OF C ONG O Table of Contents Table of Contents iii Table of Tables vi Table of Figures vi Acronyms ix Acknowledgments xiii Executive summary xv 1. Background and methodology 1 1.1 BACKGROUND 1 1.2 REGIONAL CONTEXT 2 1.3 ASSESSMENT PURPOSE, SCOPE, AND GEOGRAPHIC FOCUS 2 1.3.1 Purpose and scope 2 1.3.2 Definitions 4 1.3.3 Assessment methodology 4 1.3.4 Limitations 6 1.4 OVERVIEW OF THE REPORT 6 2. Introduction to the private health sector in the DRC 7 2.1 KEY REGIONAL THEMES 7 2.2 HEALTH SYSTEM STRUCTURE 7 2.2.1 The public health sector 8 2.2.2 The private service delivery health sector 8 2.2.3 The private pharmaceutical sector 10 2.2.4 Traditional practitioners 10 3. Leadership and governance 12 3.1 INTRODUCTION 12 3.1.1 Private health sector regulation 12 3.2  PRIVATE ENGAGEMENT AND PARTNERSHIPS 14 3.2.1 Fora for public–private dialogue in the health sector 14 3.2.2  PPPs for health 15 3.2.3 Corporate engagement 16 iii 3.3 RECOMMENDATIONS 18 3.3.1 Regulation 18 3.3.2 Public–Private Dialogue 18 3.3.3 Partnership Strategy 20 4. Service delivery 22 4.1 INTRODUCTION 22 4.2 FAMILY PLANNING 23 4.2.1 Context 23 4.2.2 Service delivery dynamics 23 4.3 MATERNAL HEALTH 28 4.3.1 Context 28 4.3.2 Service delivery dynamics 29 4.4 CHILD HEALTH 30 4.4.1 Context 30 4.4.2 Service delivery dynamics 30 4.5 NUTRITION 32 4.5.1 Context 32 4.5.2 Strategic collaboration and advocacy 32 4.5.3 Service delivery dynamics in nutrition 32 4.6 OTHER HEALTH AREAS 33 4.6.1 Malaria 33 4.6.2 Sexually transmitted infections and HIV/AIDS 33 4.6.3 Tuberculosis 33 4.7 SERVICE DEMAND 34 4.8 RECOMMENDATIONS 36 5. Access to essential medicines 38 5.1 OVERVIEW OF THE SUPPLY CHAIN 38 5.2 PUBLIC/NGO SUPPLY CHAIN 39 5.3 COMMERCIAL SECTOR SUPPLY CHAIN 40 5.3.1 Local manufacturing 40 5.3.2 Importers and wholesalers 41 5.3.3 Pharmacies and drug shops 41 5.4 ACCESSIBILITY AND PRICING OF DRUGS 42 5.5 REGISTRATION AND PHARMACOVIGILANCE 43 5.6 RECOMMENDATIONS 44 5.6.1 Reinforce the FEDECAME System 44 5.6.2 Reform Pharmaceutical Distribution 45 iv Encourage local manufacturing and support 5.6.3  the development of the supply chain 46 6. Financing 48 6.1 HEALTH FINANCING 48 6.1.1 Health expenditure: sources, trends, and implications 48 6.1.2 The DRC’s approach to reaching UHC 48 6.1.3 Health-financing programs in the DRC 50 6.1.4 Relevant lessons learned from global experience 55 6.1.5 Recommendations 56 6.2 ACCESS TO FINANCE 58 6.2.1 Overview of the supply of financing – the banking and microfinance sector 58 6.2.2 Role of financial institutions in the private health sector 60 6.2.3 Demand for access to finance 61 6.2.4 Recommendations 63 7. Health workforce 66 7.1 DEVELOPMENT AND REGULATION OF THE PRIVATE HEALTH WORKFORCE 66 7.2 PRIVATE MEDICAL TRAINING INSTITUTES 66 7.2.1 Types of training institutions 66 7.2.2 Quality of training 68 7.3 HRH IN THE PRIVATE SECTOR 69 7.3.1 Data on HRH in the private sector 69 7.3.2 Dual practice 71 7.4 RECOMMENDATIONS 71 8. Health information systems 74 8.1 NATIONAL HEALTH INFORMATION SYSTEM AND THE PRIVATE SECTOR 74 8.1.1 DHIS2 74 8.2 OTHER INFORMATION SYSTEMS 77 8.2.1 Logistics management and information system 77 8.2.2 Health workforce information systems 78 8.2.3 Integrated Health Project data dashboard 78 8.3 DIGITAL AND TELECOMMUNICATIONS OVERVIEW 78 8.3.1 Mobile network operators 78 8.4 DIGITAL INNOVATIONS IN HEALTH 80 8.4.1 WapiMed: a digital solution for identifying and accessing health services 80 8.4.2 M-Tiba: a digital foundation for health financing 80 8.5 RECOMMENDATIONS 81 v 9. Three-year road map for action 85 10. Conclusion 104 Appendixes 105 References 112 TABLE OF TABLES Table 1. Key assessment findings and opportunities xvi Table 2. Ease of doing business in the DRC 2 Table 3. General and health characteristics for focus provinces 3 Table 4. Structure of the health system in DRC 8 Table 5. Pharmaceutical manufacturers, authorized private wholesalers, wholesalers, and authorized pharmacies in the DRC*, 2017 38 Table 6. Medicine registration efficiency and effectiveness 43 Table 7. Average out-of-pocket health expenditure by type of provider* 49 Table 8. Population coverage of selected health mutuelles 52 Table 9. Foreign Direct Investment, net inflows as percentage of GDP 58 Demand and supply side barriers to engagement of micro, Table 10.  small and medium-sized enterprises by financial institutions 61 Table 11. Private health sector lending issues 62 Table 12. Secondary level institutions by ownership and province 67 Higher education institutions for technical medicine by Table 13.  ownership and province 67 Universities with faculties of medicine and pharmacy by Table 14.  ownership and province 68 Human resources for health by category and by sector Table 15.  in the DRC, 2015 70 Number and type of facilities registered in DHIS2 in selected Table 16.  provinces, 2017 75 Table 17. MNO User Base and Market Share 79 TABLE OF FIGURES Figure 1. Health system pillars 4 Figure 2. Assessment’s geographic scope 5 Figure 3. Distribution of hospital structures by type, 2017 9 Figure 4. Distribution of hospital structures by type and by province*, 2017 9 Figure 5. Distribution of the 1,288 authorized private health care structures by province*, 2017 10 vi Figure 6. NCIFP scores by dimension 13 Figure 7. Health zones with FBO reference hospitals, 2016 16 Figure 8. Role of the PPP Unit within the MSP 21 Figure 9. Availability of medicines and products in health facilities by type of service and sector 22 Use of modern contraceptive methods in the DRC Figure 10.  and other countries 23 Figure 11. Modern contraceptive method mix by age 24 Figure 12. Regional comparison of source of FP methods 24 Figure 13. Family planning source by wealth quintile 25 Figure 14. Contraceptive methods by source 25 Figure 15. FP source by age 26 Figure 16. New FP users in 2016 26 Figure 17. Pharmacies and facilities offering FP in Kinshasa, 2013 27 Percent of private facilities in Kinshasa offering FP with methods Figure 18.  in stock on day of interview 28 Percent of private facilities in Kongo Central offering FP with Figure 19.  methods in stock on day of interview 28 Figure 20. Place of live births 29 Figure 21. Source of child health care in the DRC 31 Figure 22. Source of child health care by wealth quintile 31 Source of child health care for the lowest wealth quintile Figure 23.  in select sub-Saharan African countries 31 Number of people developing TB, on treatment, and Figure 24.  successfully treated, 2010-2016 34 Figure 25. Main reasons for nonuse of health care in the DRC, 2013 35 Percentage of non-users of FP by type reporting reason Figure 26.  for non-use 35 Figure 27. Four-pronged approach to improve ORS and zinc use 37 Figure 28. Outlets stocking modern contraceptive methods 42 Figure 29. Current expenditure by source of financing, 2014 48 Share of out-of-pocket expenditure as a percentage of total Figure 30.  health expenditure, 2016 49 Average out-of-pocket health expenditure by insurance Figure 31.  status, 2010 50 Distribution of banks (% of total number of branches Figure 32.  and bank windows) 59 Distribution of MFI (% of total number of branches and Figure 33.  MFI windows) 59 vii Figure 34. Borrowing by source (age 15+), 2011 59 Figure 35. Use of mobile money accounts in the DRC, 2016 60 Availability of trained HRH and protocols by type of Figure 36.  service and sector 71 Location of private practice among surveyed public health Figure 37.  workers who conduct dual practice, 2015 72 Figure 38. Reporting Rate for November 2017, by Facility Type 76 viii Acronyms ABEF Association pour le Bien-Être Familial Abt Abt Associates ACT Artemisinin-based combination therapy ARCA Autorité de Régulation et de Contrôle des Assurances ASF Association de Santé Familiale ASPS Alliance du Secteur Privé de la Santé ASRAMES Association Régionale d’Approvisionnement en Médicaments Essentiels B&MGF Bill & Melinda Gates Foundation BDOM Bureau Diocésain des åuvres Médicales/catholiques CDR Centrale de Distribution Régionale des Médicaments CLC Community life center CNMN Comité National Multisectoriel de Nutrition CNP-SS Comité National de Pilotage du Secteur de la Santé CODESA Comité de Développement de l’Aire de Santé CPN Commission Pharmaceutique Nationale CPR Contraceptive prevalence rate CTMP Comité Technique Multisectoriel Permanent pour le repositionnement de la planification familiale en RDC DCA Development credit authority DHIS2 District Health Information System 2 DHS Demographic and Health Survey DPM Direction de la Pharmacie et du Médicament DPS Division Provinciale de la Santé DRC Democratic Republic of Congo FBO Faith-based organization FDI Foreign direct investment FEDECAME Fédération des Centrales de Distribution des Médicaments Essentiels FINCA Foundation for International Community Assistance FP Family planning ix GAHN Global Access Health Network GDP Gross domestic product GSK GlaxoSmithKline HRH Human resources for health iHRIS Human Resource Information Solution IFC International Finance Corporation IHP Integrated Health Project (USAID) IMNCI Integrated Management of Neonatal and Childhood Illnesses LMIS Logistics Management Information System MCH Maternal and child health mCPR Modern contraceptive prevalence rate MESP Mutuelle de Santé de l’Enseignement Primaire, Secondaire et Professional MFI Microfinance institutions MOCC Mouvement Ouvrier Chrétien du Congo MSME Micro, Small, and Medium Enterprises MSP Ministère de la Santé Publique NCIFP National composite index to rate the enabling environment for family planning NGO Nongovernmental organizations OCC Office Congolais de Contrôle ORS Oral rehydration solution PBF Performance-based financing PEPFAR President’s Emergency Plan for AIDS Relief PMA2020 Performance Monitoring and Accountability 2020 PMI President’s Malaria Initiative PMTI Private medical training institute PNAME Programme National d’Approvisionnement en Médicaments Essentiels PNDS Plan National De Développement Sanitaire PNLP Programme National de Lutte contre le Paludisme PNPMS Programme National de Promotion des Mutuelles de Santé PNSR Programme National de Santé de la Reproduction POMUCO Plateforme des Organisations Promotrices des Mutuelles de Santé du Congo PPP Public–private partnership PRONANUT Programme National de Nutrition PSI Population Services International x SARA Service Availability and Readiness Assessment SBC Social and behavior change SNIS Système National d’Information Sanitaire TB Tuberculosis TPA Third-party administrator U5M Under-five mortality UHC Universal health coverage UMUSAC Union des Mutuelles de Santé du Congo UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID U.S. Agency for International Development UHC Universal Health Coverage WB World Bank WHO World Health Organization xi Acknowledgments The assessment team is grateful for the support of Hadia Samaha and Kara Adamon from the World Bank for guiding the development, writing, and review of this report. We also thank the International Finance Corporation for cofinancing the assessment. We also thank collaborators from the Bill & Melinda Gates Foundation, including Tanya Shewchuk and Perri Sutton; those from the United States Agency for International Development, including Lois Schaefer, Jasmine Baleva, Nefra Faltas, Malia Boggs, and Izetta Minko-Moreau; and the Global Financing Facility in Support of Every Woman Every Child (GFF). We thank the Ministry of Public Health, particularly Minister of Health Dr. Oly Ilunga Kalenga, and the Private Sector Advisor to the Minister, Jean-Julien Ilunga, for their assistance and kindness during the assessment. We appreciate the time and insights about the private health sector provided by stakeholders from non- profit organizations, development partners, implementing partners, private clinics and pharmacies, and private sector health associations. Finally, we also thank Caroline Quijada of Abt Associates for her leadership of the assessment and review of the document and recommendations to improve it. Recommended Citation: Bettina Brunner, Virginie Combet, Sean Callahan, Jeanna Holtz, Emily Mangone, Jeff Barnes, Cathy Clarence, Auguste Assi, and Stephanie Gober. 2018. The Role of the Private Sector in Improving the Performance of the Health System in the Democratic Republic of Congo. Bethesda, MD: Abt Associates Inc. Acknow le dg m e nts xiii Executive Summary The World Bank, in partnership with the International Finance Corporation (IFC), the Bill and Melinda Gates Foundation (B&MGF), and the United States Agency for Interna- tional Development (USAID), engaged Abt Associates (Abt) to conduct an assessment of the role of the private sector in improving health system performance in the Demo- cratic Republic of Congo (DRC). The assessment uses the World Health Organization’s (WHO’s) six health system pillars as a framework: leadership/governance, service deliv- ery, access to essential medicines, financing, health workforce, and health information systems. The assessment included eight focus regions to reflect the geographic diver- sity in size and composition of the private health sector: Kinshasa, Matadi, Lubumbashi, Kolwezi, Bukavu, Goma, Mbuji-Mayi, and to a limited extent, Kisangani. The assessment provides: yy An estimate of the size, scope, and scale of the private health sector, with an empha- sis on key stakeholders and their roles; yy An overview of the types of health services and products offered by the private sector with particular focus on family planning (FP) and maternal and child health (MCH); yy Benchmarks and lessons from comparable low-income countries; yy An overview of policies, market conditions, and business needs that inhibit or enable private sector participation in the health system; and yy Strategic priorities with a three-year road map for action. Abt finalized the scope of work with the World Bank, the IFC, the B&MGF, USAID, and the Ministry of Health (Ministère de la Santé Publique, MSP) and conducted a launch event in October 2017. Following the launch, a team of private sector experts completed an extensive desk review of over 200 documents, followed by a data collection trip to the DRC to interview 215 stakeholders in the seven priority geographic areas (excluding Kisangani). The findings, recommendations, and opportunities presented in this report are complemented by a prioritized three-year road map, a plan developed as part of a validation and prioritization effort in April 2018. KEY FINDINGS AND RECOMMENDATIONS The private health sector is an important player in the DRC’s health system, but the extent of its contribution remains largely unknown. Private providers, especially faith- based organizations (FBOs), grew in scale during the late 1990s and early 2000s to fill gaps that emerged in the public health sector as a result of political and civil destabili- zation. As the government sought to reestablish itself and improve health outcomes, it recognized the importance of private providers and sought to integrate them into the larger health system—the private sector is now mentioned as a key partner in several MSP Execu ti ve S u m m a ry xv strategies, policies, and plans. However, public–private engagement for health remains nascent, with the notable exception of FBOs. Efforts by the central level to improve engagement have been slow as the government simultaneously seeks to decentralize the health system to provincial and lower levels of government. Overlapping areas of responsibility between these levels, combined with financial and human resource defi- cits, as well as limited data about who and where the private sector is, have all further decelerated efforts to engage and regulate the private sector. The private health sector itself faces numerous constraints related to the availability of commodities, shortages of adequately trained staff, and financial affordability of private health care. Further- more, continued political uncertainty has deterred increased corporate investment in the health system. Despite these obstacles, there are numerous opportunities for the DRC’s government and donors to better leverage private actors and improve health outcomes. Table 1 summarizes key findings and recommendations identified as part of the assessment process. Table 1.  Key assessment findings and recommendations Findings Recommendations Integration of private sector in decision making and implementation of health sector strategy Leadership and Governance Leadership and Governance yy Alliance du Secteur Privé de la Santé (ASPS) is unclear of yy Provide targeted technical assistance to strengthen its role and mandate to advocate for private sector. national and regional ASPS presence and advocacy. yy There are insufficient forums for the private for-profit yy Strengthen ASPS’s ability to organize provider trainings, sector to meet regularly with the public sector and work with financial institutions to identify facilities in resolve challenges or collaborate. In addition, there is no need of financing, and build connections between provid- uniform process for engaging FBOs already partnering ers and financial institutions. with the government. yy Increase public–private dialogue at the national and yy MSP restructuring has created institutional barriers to health zone levels through forums and implementation of quick decision making and autonomy needed for public– the FBO convention currently under review. private partnerships (PPPs). MSP also lacks a strategy yy Build the MSP’s capacity to better leverage PPPs, for health PPPs. including support to develop a health PPP strategy and Service Delivery strengthen the capacity of the Direction de Partenariat yy The DRC government has developed an integrated infant, to transition to a higher profile PPP unit and serve as neonatal, maternal and child health strategy but has not focal point for private sector engagement. fully implemented it to improve health outcomes. Service Delivery yy Private providers do not receive regular updates about FP yy Leverage an integrated approach to improve child health and do not routinely counsel on FP. case management that includes securing a conducive Private Sector Supply Chain and Systems policy and regulatory environment; ensuring wide avail- yy Donor procurements (for example, for President’s Emer- ability of high-quality, affordable products; generating gency Plan for AIDS Relief [PEPFAR], Global Fund, and the demand and educating caregivers about appropriate President’s Malaria Initiative) occur outside (FEDECAME) care-seeking behavior; and improving private provider systems. knowledge and skills. xvi T H E ROL E OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCR ATIC RE PUBL I C OF C ONG O Table 1.  Key assessment findings and recommendations (Continued ) Findings Recommendations Integration of private sector in decision making and implementation of health sector strategy Health Financing yy Leverage and strengthen existing provider networks and yy The DRC has recently passed legislation (Loi Organique franchises to reinforce private provider training on FP no.17/002 du 8 février 2017) that will enable scale-up of counseling and service provision. coverage in community-based mutuelles, as well as other Private Sector Supply Chain and Systems financing mechanisms, such as mandatory health insur- yy Encourage collaboration among donors, international ance for civil servants. nongovernmental organizations (NGOs), and FEDECAME yy Health financing programs vary, with ad hoc manage- to improve the national system for commodity forecast- ment structures, payment arrangements, and adminis- ing and procurement. trative processes. Programs usually purchase services Health Financing through fee-for-service models and struggle to manage risks of moral hazard and fraud. yy Establish an advocacy forum for mutuelles to engage gov- ernment and other key stakeholders to implement and yy The DRC has piloted performance-based financing (PBF) monitor adherence to common performance standards schemes to help improve health system performance. To focused on clinical care, service mix, pricing and billing date, schemes have largely excluded private providers. practices, reporting, and patient service standards. Health Workforce in the Private Sector yy Support expansion of strategic purchasing for health yy Human resources for health (HRH) data in the private financing programs, including contracting, which includes sector are limited because not all stakeholders report to new models for quality assurance of contracted private the MSP. providers. yy Private providers say that FBOs and NGOs are favored by yy Validate successes and challenges of PBF and the extent the MSP above for-profit health facilities for contracting. to which they have engaged private providers. Test yy Initiatives to increase HRH motivation are limited by the whether and how PBF can promote quality and efficiency MSP’s inability to pay the salaries of its staff in public in the private sector. facilities and private facilities they are contracting with. Health Workforce in the Private Sector yy Training plans exist for all levels of HRH, but the quality yy Support MSP to collaborate with public and private sec- and accessibility of training varies because of inadequate tor stakeholders to better map the HRH available in the resources and trainers, as well as geographic/financial private sector across key health areas to identify and constraints. address HRH gaps. Information Systems and Digital Health Initiatives yy Develop and implement with the MSP’s Directorate of yy Limited information is available about what drugs and Human Resources a systematic approach to improve commodities are registered. HRH motivation in both the public and private sector in collaboration with partners. yy Private sector data are routinely collected and include high levels of private sector reporting for those regis- yy Support MSP to work with partners, including orders tered, an achievement that needs to be continuously rein- and provider associations, to improve training programs forced and incentivized. across public and private training institutions, including programs for trainers. yy District Health Information System 2 (DHIS2) FP and child health data are limited and do not provide a com- Information Systems and Digital Health Initiatives plete picture of commodity supply or demand. yy Establish a comprehensive web-based database of reg- yy The logistics management information system (LMIS) is istered drugs and approved lots for frequently used insufficient to monitor and strengthen the supply chain. medicines. (continues on page xviii) Execu ti ve S u m m a ry xvii Table 1.  Key assessment findings and recommendations (Continued ) Findings Recommendations Integration of private sector in decision making and implementation of health sector strategy yy The percentage of private facilities in the DRC registered yy Continue to build a culture of data reporting and use by in DHIS2 is unclear. Of the facilities that are registered, acknowledging private sector priorities, challenges, and nearly 3,000 are not categorized as public, private, or incentives. faith-based, making it difficult to assess differences in yy Review and improve FP and child health indicators in DHIS2. participation by sector or health indicators. yy Support development of a LMIS platform, such as Open- yy No internal reports are generated recurrently to provide LMIS, that is separate from and interoperable with DHIS2, decision makers with insight into differences in public for stock management. Although the public sector would and private service delivery or to offer feedback to pri- manage the LMIS, private sector engagement would be vate providers. critical to its success and utility. yy Steady progress has been made toward implementing a yy Conduct a private sector survey to map private health human resource information solution (iHRIS) to collect facilities in the DRC, including pharmacies and drug and manage data on HRH numbers, skills, qualifications, shops, to improve participation in DHIS2 and the LMIS. locations, and other important data for decision making. yy Develop and distribute actionable data dashboards for These data can enable policy makers to identify critical decision making in the private sector. resource gaps and priorities. yy Continued technical support is needed to scale the iHRIS yy The Integrated Health Project (IHP) is initiating a data nationally to address significant health workforce chal- dashboard for health program decision making at the lenges. Stronger engagement with for-profit and nonprofit health zone level. providers could help balance and distribute human capital. yy Explore increasing private sector integration in the new IHP data dashboard Regulation of the private sector Leadership and Governance Leadership and Governance yy There is no Order of Midwives in the DRC to help regulate yy Support the establishment of an Order of Midwives. this cadre. Private Sector Supply Chain and Systems Private Sector Supply Chain and Systems yy Assess the feasibility of revising the customs and taxation yy The customs and taxation regime is not differentiated for regime to incentivize local manufacturing. the import of primary inputs and final products, which Health Workforce in the Private Sector increases costs for local manufacturers. yy Work with the MSP’s new Directorate of Human Resources Health Workforce in the Private Sector in collaboration with the Ministry of Primary, Secondary yy There are significant variations in the quality of private and Professional Education and the Ministry of Higher Edu- sector HRH, arising from a lack of clarity in the accredi- cation to institute a coordinating body that can facilitate tation process for training institutions, inadequate avail- the regulation and standardization of training programs ability of resources, and inadequate training quality. and improve the quality and standardization of training. yy The accreditation process for training institutions is yy Establish and enforce a uniform accreditation system for unclear because of the influence of multiple actors. training institutions. yy Some students are entering post-graduation clinical care yy Clarify and codify standard operating procedures related without sufficient practical training, which negatively to the placement of private students (all cadres and dis- affects the quality of care ciplines) in public facilities. xviii T H E ROL E OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCR ATIC RE PUBL I C OF C ONG O Table 1.  Key assessment findings and recommendations (Continued ) Findings Recommendations Improved environment for private sector investment Leadership and Governance Leadership and Governance yy Conduct a legal and regulatory review to identify regula- yy Generally, legislation currently inhibits access to private tory articles related to the private health sector needing health services and products. reform. yy The current customs and taxation regimes raise the costs yy Encourage local drug manufacturing through policy of local production of medicines and the costs that reform, technical support, access to financing, and revis- consumers pay for imported commodities. ing customs and taxation regimes. Service Delivery Service Delivery yy Cost is a major barrier to the use of FP services in the pri- yy Explore opportunities to expand current PPP efforts for vate sector. vaccines to include FP commodities. Private Sector Supply Chain and Systems Private Sector Supply Chain and Systems yy The decentralized regional supply chain network, FEDE- yy Through existing programs from the World Bank and CAME, has limited capacity and requires new financing other partners, provide technical support to FEDECAME strategies to manage bad debt risk. beyond procurement, storage, and logistical issues to yy Regional distribution centers need to improve debt man- include cost controls, marketing, and risk management. agement to grow operations. yy Assist the entire FEDECAME network (including regional yy The private sector supply chain is heavily fragmented centers) to access new financing opportunities and man- and in need of a major overhaul, as well as capacity age bad debt. strengthening to deliver and handle medicines according yy Strengthen the private supply chain by building capac- to pharmaceutical norms. ity of regional distributors to handle medicines; building yy The major barrier for local manufacturers is their failure public-sector capacity to supervise and enforce drug to achieve the quality standards that would allow them regulations and inspect pharmacies; raising the quality to participate in FEDECAME and international organiza- standards of drug wholesalers; and defining a new scope tion tenders. of practice for second-tier drug shops that can sell a lim- ited range of essential medicines. Health Financing yy Provide technical support through the WHO to manufac- yy The DRC lacks a culture of insurance among citizens, lim- turers to improve quality. iting demand for insurance. Health Financing yy The majority of health financing programs focus on ther- apeutic care rather than preventive services, such as FP. yy Collaborate with the Autorité de Régulation et de Con- trôle des Assurances (ARCA; new insurance regulator), yy Private providers have limited experience with or know- insurance companies, mutuelles, health providers, and how to work with health financing programs, and their other actors to educate consumers about insurance, and clinical and service standards vary widely. pilot an insurance program targeted at informal, vulner- Access to Finance able groups. yy The ASPS could be a valuable partner to expand financing yy Collaborate with mutuelles and corporate sponsors to for the private health sector. cover FP and preventive health services and products. yy Health providers often have weak business and financial yy Strengthen readiness of private providers to partici- management capacity and are unable to provide finan- pate in mutuelles and other health financing initiatives cial statements or accounts history to prove their repay- by developing a scalable provider network with common ment capacity to financial institutions. quality, pricing, and treatment standards. (continues on page xx) Execu ti ve S u m m a ry xix Table 1.  Key assessment findings and recommendations (Continued ) Findings Recommendations Improved environment for private sector investment yy Many private health providers are unable to access yy Strengthen health financing programs by building the financing from banks and microfinance institutions, and capacity of mutuelles in product design, pricing, risk man- those who are able to borrow face significant collateral agement, and administrative processes through mutuelle requirements, restrictively short loan terms, and very support organizations. Test models to scale mutuelles in high interest rates. partnership with microfinance institutions, associations, or cooperatives. yy Explore ways to use technology to improve the efficiency of health financing programs. Access to Finance yy Strengthen the capacity of ASPS to support the private health sector, including by organizing business training sessions for providers; maintaining a members’ database to advise financial institutions on potential clients; and providing general information about the private health sector that could be used in training for financial insti- tutions. yy Provide business and financial management training and counseling for private health providers. yy Evaluate the potential to develop partnerships and mar- ket links within the health ecosystem that would gener- ate benefits to all parties. Opportunities for private sector investment Leadership and Governance Leadership and Governance yy Work with pharmaceutical, medical device, and technol- yy International pharmaceutical and medical device man- ogy companies (for example, Phillips and MasterCard) to ufacturers support market research and various social bring and/or scale up new products that improve access programs in the DRC, even without a local presence. to and delivery of health services. Service Delivery Service Delivery yy Private sector engagement in nutrition programs remains yy Support strategic interventions to engage the private relatively limited. sector in nutrition programs, including promoting local Private Sector Supply Chain and Systems food fortification, leveraging private transporters to yy Congolese law permits nonpharmacists to own a phar- move therapeutic products to difficult areas, and increas- macy, provided the owner employs a pharmacist to over- ing private participation in strategy and planning. see operations and follow professional standards. This Private Sector Supply Chain and Systems regulation creates an opportunity for owners to develop yy Encourage the creation of pharmacy and drug shop networks of pharmacies and achieve economies of scale. networks. xx T H E ROL E OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCR ATIC RE PUBL I C OF C ONG O Table 1.  Key assessment findings and recommendations (Continued ) Findings Recommendations Improved environment for private sector investment Health Financing Health Financing yy Health financing programs run by third party adminis- yy Support a third-party administrator (TPA) or employer to trators or private sector employers often face challeng- develop and scale up an improved model to administer an es related to provider payments, costs, or fraud, among employee benefit program. others. Access to Finance Access to Finance yy Partnerships between equipment suppliers and banks yy It is difficult for private providers to obtain financing to can develop (for the bank) a pipeline of clients needing build or expand their practice. loans to purchase equipment and (for the supplier) a source of financing. Work with financial institutions to yy There are few organizations in the DRC positioned to expand lending to the health sector, potentially through provide technical assistance to health enterprises that a risk-sharing mechanism (such as a USAID Development would enable them to be investor ready. Credit Authority portfolio guarantee), identify medium or Information Systems and Digital Health Initiatives longer-term funding, and provide technical assistance to yy Although many implementing partners are raising aware- banks to reduce the cost of lending to the health sector. ness about key health areas, there is no coordinated yy Assess the landscape for health enterprises and deter- approach to partnering with telecommunications agencies, mine the most promising activities to jump-start health such as Orange, Vodacom, Airtel, and Africell, which have companies. large physical, virtual, and human networks across the Information Systems and Digital Health Initiatives DRC and can be leveraged to improve national communi- cation infrastructure. yy Assess, harmonize, and aggregate demand for digital health services in the health sector. yy Convene implementing partners, telecommunications agencies, and the MSP to establish a digital health net- work coordinating body that harmonizes approaches to digital communication and outreach strategies for key health priorities. This includes exploring PPP opportunities for communication and data collection and transmission. Execu ti ve S u m m a ry xxi 1.  Background and Methodology 1.1 BACKGROUND With a population of 78.7 million, the DRC is Africa’s Box 1.  Foreign Direct Investment in the DRC fourth most populous country (World Bank 2016). The Obtaining reliable statistical data on FDI in the DRC country is experiencing rapid population growth, espe- remains a challenge. The largest foreign investors in the cially among youth ages 15 to 30 years (USAID 2014), DRC are Chevron Oil, with its Congo Gulf Oil subsidiary, with an expected increase of 10 million by 2050. Most Citibank, Telecel, Mobil, Group Damseaux conglomerate, of the population lives in poverty and is not active in the Bralima brewery, UNIBRA brewery, Tabacongo/Rothman formal economy. The National Institute of Statistics found Corp., Hasson Group, and BAT Congo. that the DRC’s informal sector represented 89 percent of Source: Mia n.d. total economic activity in 2012 (export.gov 2017b). Despite natural resource wealth and significant donor investment, the DRC has experienced limited improve- ments in its economic and development outcomes. credit registry known as the “centrale des risques” in the Declines in the global price of minerals and petroleum Banque Centrale. In addition, the government has created have led to slower economic growth in recent years. Gross the National Agency for Investment Promotion, which domestic product (GDP) grew only slightly between 2015 uses provisions of the new Investment Code to simplify and 2016, from $37 billion to $38.5 billion (2.4 percent, investments and make the procedures more transparent. down from 6.9 percent in the previous year). Inflation Probusiness incentives range from tax breaks to duty increased from 1 percent to 12 percent between 2015 and exemptions granted for three to five years, and are 2016. Ongoing political instability discourages investment, dependent upon the location and type of enterprise, the diverts attention from economic issues, and increases the number of jobs created, the extent of training and pro- cost of doing business (export.gov 2017b). Foreign direct motion of local staff, and the export-producing potential investment (FDI) statistical data are unavailable (Box 1). of the operation. The United Nations has an ongoing, large-scale peace- Table 2 lists the DRC’s “Doing Business” rankings by topic. keeping operation in the east of the DRC, where violence The DRC ranked 182 of 190 countries in 2017—although persists because of the presence of several militias and reforms have made it easier to start a business, there foreign armed groups (U.S. Department of State 2016). remains significant room for improvement (World Bank 2017d). On a scale of 0 to 100, the Millennium Challenge Corporation (MCC) gave the DRC high marks for fiscal Ease of doing business policy (94) and business start-up (76) but low marks In recent years, the DRC has made it easier to start in regulatory quality (18), access to credit (24), control a business, including in health, by combining multiple of corruption (18), and government effectiveness (20) registration procedures, reducing the time required to (MCC 2017). obtain a building permit, and eliminating the require- ment for a woman to obtain her husband’s permission to start a business (World Bank 2017a; 2017d). The DRC Health outcomes has also established a one-stop shop for opening a busi- Despite gradual improvements in some key health indica- ness and accessing credit information by establishing a tors, two decades of conflict and ongoing insecurity have BACKGR OU ND AND METH O DO LO GY 1 Table 2.  Ease of doing business in the DRC (Barroy et al. 2014). However, the DRC is one of five countries that collectively accounts for half of all deaths Doing Busi- globally among children younger than five (WHO 2012). Topics ness Sixty percent of children younger than five nationwide 2018 Rank are not covered by basic treatment services for diarrhea, Overall 182 fever, and respiratory infections (Barroy et al. 2014). Use Starting a business  62 of oral rehydration solution (ORS) and zinc remains Dealing with construction permits 121 low, even in provinces with large urban areas, such as Getting electricity 175 Katanga, where use of ORS and zinc is at 38.3 percent Registering property 158 and 0.9 percent, respectively (MPSMRM, MSP, and ICF Getting credit 142 International. 2014). The DRC also has high rates of mal- Paying taxes 181 nutrition, which has significant economic consequences Enforcing contracts 172 amounting to 4.5 percent of GDP lost annually (World Source: World Bank 2017d rankings of 190 countries. Food Programme 2017). led to a significant deterioration in health infrastructure. 1.2  REGIONAL CONTEXT Low financing for health and weak government oversight exacerbate service inadequacies, with poor deployment The DRC is a vast country with significant regional varia- of the limited resources that are available. Structural tion in culture, economy, language, and health indicators. barriers to service access (for example, distance, lack of Many locations can be accessed only by plane or boat, transport, and prohibitive fees), combined with inequita- adding to regional differences. Kinshasa province, home ble gender norms (Box 2) and harmful cultural beliefs, to the capital city, generally outperforms the rest of the prevent service use, drive unhealthy behaviors, and further country for most health indicators. North and South exacerbate poor health outcomes. Kivu, where instability has been concentrated in recent years, have the highest rate of infant mortality. The for- Limited access to health services has resulted in some of mer Katanga province has the highest fertility rate at the worst maternal and child mortality rates in the world. 7.8 children per woman and the lowest use of contracep- The latest Demographic and Health Survey (DHS) from tives at 3.9 percent. Table 3 summarizes general health 2013–14 indicated that maternal mortality is 846 deaths characteristics for the key regions of this report. per 100,000 births. Despite relatively satisfactory antena- tal care coverage, there is a lack of emergency obstetric care. The DRC also has one of the lowest modern con- ASSESSMENT PURPOSE, SCOPE, 1.3  traceptive prevalence rates (mCPR) in Africa, with only AND GEOGRAPHIC FOCUS 8 percent of married women using a modern method 1.3.1  Purpose and scope (Barroy et al. 2014). To guide the MSP and development partners in their strat- Under-five mortality (U5M) has fallen steadily from egies and health investments, the World Bank and IFC, in 148 deaths per 1,000 live births in 2007 to 104 in 2013–14 partnership with the B&MGF and USAID, are implement- ing a private health sector assessment. This assessment supports ongoing and future government and donor Box 2.  Congolese women: a vulnerable group efforts by providing: Ninety-seven percent of Congolese women face at least yy An estimate of the size, scope, and scale of the private one constraint (that is, domestic violence or limited health sector, with an emphasis on key stakeholders economic opportunity) that limits their ability to access and their roles; health care and negatively affects their health outcomes. yy An overview of the types of health services and prod- Source: World Bank 2017a. ucts offered by the private sector, with particular focus on FP and MCH; 2 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Table 3.  General and health characteristics for focus provinces Province City General characteristics Health indicators* Kinshasa Kinshasa Capital with estimated 11 million Total fertility rate: 4.2 inhabitants; third largest urban area mCPR: 19% in Africa by population; best roads; MCH: 98% economic, diplomatic, and MSP hub U5M: 83 Malaria: 18% Kongo Central Matadi Port city with high level of movement Total fertility rate: 6.0 of contraband products mCPR: 17% MCH: 94% U5M: 124 Malaria: 24% Kasaï Oriental Mbuji-Mayi Mainly rural and sparsely populated, Total fertility rate: 7.3 with large areas inaccessible by mCPR: 4% road; site of significant conflict MCH: 72% U5M: 122 Malaria: 29% Haute Katanga Lubumbashi Provincial capital and hub for Total fertility rate: 7.8 industrial mining companies mCPR: 4% MCH: 63% U5M: 121 Malaria: 32% Lualaba Kolwezi Large mines dominate, with small Total fertility rate: 7.8 city center mCPR: 4% MCH: 63% U5M: 121 Malaria: 32% South Kivu Bukavu City with extensive donor and Total fertility rate: 7.7 humanitarian presence; significant mCPR: 8% unrest and number of internally MCH: 93% displaced persons U5M: 139 Malaria: 10% North Kivu Goma City with extensive donor and Total fertility rate: 6.5 humanitarian presence; significant mCPR: 12% unrest and sporadic violence MCH: 92% U5M: 65 Malaria: 5% Tshopo Kisangani One of the three “command centers” Total fertility rate: 5.9 for the Congolese economy along mCPR: 5% with Kinshasa and Lubumbashi; MCH: 83% important center of commerce, U5M: 112 finance, and industry Malaria: 38% Sources: DHS 2013–14 data based on the previous administrative division with 11 provinces; Discoverworld.com 2017. Total fertility rate: number of live births per woman; mCPR: using any modern method (%); MCH: births delivered in a health facility (%); U5M: deaths per 1,000 live births; Malaria: children ages 6 to 59 months who tested positive for malaria according to microscopy (%). BACKGR OU ND AND METH O DO LO GY 3 yy Benchmarks and lessons learned from comparable laboratories, diagnostic services, and pharmaceutical low-income countries; supply chain actors. yy An overview of policies, market conditions, and busi- yy PPPs: Any formal collaboration between the public ness needs that inhibit or enable private sector partic- sector at any level and the nonpublic sector (for-profit, ipation in the health system; and nonprofit, traditional healers, midwives, or herbalists) yy Strategic priorities and a three-year road map for to jointly regulate, finance, or deliver services, prod- action. ucts, equipment, research, communication, or educa- tion (Barnes 2011). The assessment uses the WHO’s six health system pillars: leadership/governance, service delivery, access to essen- yy Key health stakeholders: An individual or group who tial medicines, financing, health workforce, and health can affect or is affected by an organization, strategy, information systems (Figure 1). or policy in health. The assessment also examines regional variations, focus- ing on Kinshasa, Matadi, Lubumbashi, Kolwezi, Bukavu, 1.3.3  Assessment methodology Goma, Mbuji-Mayi, and to a limited extent, Kisangani The Abt Associates approach to private sector assess- (Figure 2). The assessment focused on urban areas gen- ments is based on the collective experience of conducting erally as they have the highest density of private health more than 30 assessments in sub-Saharan Africa, Latin facilities in the country. These cities were chosen for their America and the Caribbean, Europe and Central Asia, the geographic diversity to better identify widespread general Middle East, and Asia. The DRC assessment consisted of challenges the private sector faces in the DRC, as well as five steps: specific regional variations. yy Plan: Abt worked with the World Bank, the IFC, the B&MGF, USAID, and the MSP to finalize the assess- 1.3.2 Definitions ment scope, key questions, and schedule. The following definitions are used throughout the report: yy Learn: In preparation for fieldwork, the assessment yy Private health sector: Composed of for-profit com- team (composed of 10 international and DRC-based mercial entities and nonprofit organizations, such as specialists) conducted a comprehensive desk review NGOs and FBOs, that provide health services, prod- to understand the current state of the private health ucts, and information. Supporting these are private sector in the DRC using WHO’s health pillars as a Figure 1.  Health system pillars Leadership/ Financing Governance Access to Essential Health Information Medicines Systems Service Delivery Health Workforce 4 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Figure 2.  Assessment’s geographic scope framework. The team shared high-level findings with ment. The team compiled meeting notes and other stakeholders at a launch event in Kinshasa on Octo- quantitative and qualitative data and reviewed them, ber 24, 2017, attended by public and private sector following up on outstanding questions by telephone stakeholders, and presided over by the Minister of and e-mail. The team prepared a draft report and a Health, Dr. Oly Ilunga Kalenga. In November and road map for action based on the analysis. December 2017, the assessment team conducted key yy Share and act: The assessment team validated and informant interviews with representatives from the prioritized findings and recommendations during a private and public health sectors, development part- stakeholder workshop in April 2018. Approximately ners, and other key stakeholders in the seven focal 46 public and private sector stakeholders convened cities. Kisangani, which was added later to the list to discuss the findings, prioritize recommendations, of cities, was included in the desk research but not and validate a three-year strategic road map. Follow- in the field visits because of security concerns. This ing the workshop, both public and private stake- report is a summary of the desk research and stake- holders had the opportunity to provide additional holder interviews, and presents key findings and feedback in writing. The team then produced the recommendations. final report, which includes the Current State and yy Analyze: Analysis began during the stakeholder inter- Opportunity Assessment, as well as the Three-Year views and continued as the team wrote the assess- Road Map for Action. The MSP and its development BACKGR OU ND AND METH O DO LO GY 5 partners will be able to use the report’s findings and that some of this analysis may be incomplete or out of recommendations to build strategic partnerships with date with more recent developments given the time lag the private sector to improve health outcomes. in data collection for these studies. 1.3.4 Limitations 1.4  OVERVIEW OF THE REPORT In general, the DRC has limited high-quality data avail- This report provides a comprehensive overview of pri- able about the private health sector. The country lacks a vate sector participation in the DRC’s health system robust system for collecting routine data about the num- based on existing literature and data sources and using ber of private providers, their role in delivering health WHO’s six pillars of health as a framework. The assess- products and services, and the quality of those services. ment provides a brief overview of the health system and These data gaps mean that the assessment team relied key actors, including the size, scope, and scale of private on data generated by periodic donor-funded studies, such sector providers; assesses the enabling environment for as the Demographic and Health Surveys and Service Avail- the private sector; and provides benchmarks and lessons ability and Readiness Assessments. This reliance means learned from comparable low-income countries. 6 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Introduction to the Private Health 2.  Sector in the DRC 2.1  KEY REGIONAL THEMES uncertainty, the environment in the DRC is not conducive to corporate investment. However, opportunities may exist Although each province has its own identity, there are to expand current social investments by multinational a few key similarities across regions identified by the corporations to address health-related concerns. assessment that affect the private health sector, as described here. Lack of funding and transparency inhibits MSP’s ability to regulate the private health sector. The persistent Ongoing decentralization is impeding integration of the budget deficit means there is insufficient funding for private health sector. As could be expected, the move supervision of health enterprises or enforcement of health from 11 to 26 provinces and reorganization of the MSP standards. Lack of compensation for public-sector staff from 13 to seven directions has been disruptive. During leads to increased dual practice by health professionals. the transition period, national, provincial, and health At all levels of government, inadequate compensation zone staff are unsure of their new roles, procedures, and can also contribute to misappropriation of resources or reporting requirements, especially with regard to the pri- informal facilitation fees. vate health sector. Inspectors are still following old geo- graphic boundaries, whereas new inspectors are needed Critical system bottlenecks impede the functionality of in new provinces. The rollout of professional orders from the private health sector. The private health sector faces 11 to 26 provinces is incomplete, and new roles within challenges with accessing quality commodities because each province are not yet defined. This lack of clarity brands on the market change quickly depending on avail- exacerbates marginalization of the private sector at the able imports. With insufficient oversight of health training national, provincial, and health zone levels. facilities, medical graduates have varying levels of skills. Given the high poverty rate in the country, the private MSP’s desire to increase engagement of the private health sector in all provinces faces difficulties with grow- health sector is not yet operational. The MSP, particularly ing health businesses. under the new minister, is keen to increase engagement of the private health sector, which is cited in many strat- egies and policies as an important stakeholder. However, 2.2  HEALTH SYSTEM STRUCTURE although FBOs and NGOs are included to varying degrees The 2016–20 National Health Development Plan (Plan in the strategic planning process, private for-profit groups National de Développement Sanitaire 2016-2020, PNDS) are not routinely included in any planning or policy dis- identifies four main health sectors: public medical, pri- cussions. At the provincial and district levels, there is no vate medical, private pharmaceutical, and traditional forum for the private sector to discuss challenges or (see Table 4). partnerships with the public sector. The PNDS builds on health sector decentralization that Political uncertainty deters corporate investment, result- began in 2006 with the National Health System Strength- ing in a “wait and see” attitude. There are opportunities ening Strategy (Stratégie de Renforcement du Système in the DRC for multinational corporations to expand their de Santé), mandating division of the country’s existing social investment and address health-related concerns. 11 provinces into 26 (Wright 2015). The MSP is devolving However, companies and investors seek a stable envi­ authority to the 26 new provincial health divisions (Divi- ronment as a prerequisite to launch operations or invest sion Provinciales de la Santé, DPS), but the process is in a country. Because of ongoing conflict and political incomplete. I NTR ODU CTI ON TO THE PR I VATE HEALTH SECTOR IN T H E DR C 7 Table 4.  Structure of the health system in the DRC Public Medical Private Medical Sector Private Pharmaceutical Traditional Sector For-profit Nonprofit Sector Medicine Health centers, general Private medical Health centers Pharmaceutical companies Traditional healers reference hospitals, and paramedical and hospitals and authorized wholesale, using plants and provincial and national practices, clinics, managed by NGOs supply, and distribution traditional practices to hospitals, other polyclinics, and (including FBOs) structures diagnose diseases and state and parastate diagnostic centers conditions and provide structures involved care for patients in service delivery 2.2.1  The public health sector Health zones (Zones de Santé) are the lowest constituent of the public health sector. There are 516 zones across The MSP is responsible for the health system and cre- the country, led by a management team under the direc- ates national strategies, defines policies and priorities, tion of a zonal medical officer and covering 100,000 to and sets standards and guidelines for service delivery. 150,000 inhabitants with a general referral hospital. Three Within the MSP, the existing 13 departments are being hundred ninety-three health zones have government-run restructured into seven central directorates to oversee general reference hospitals, and the remaining 123 have HRH, strategic planning, service delivery, pharmacy and either a faith-based hospital or a private health facility that medicines, disease control, health education, and family serves as the reference hospital for the zone (President’s health. In addition, the government is launching two new Malaria Initiative [PMI] 2017). Health zones are further bro- cross-cutting directorates focused on financial affairs ken down into 8,504 health areas, each of which operates and technology. The MSP also implements several health a health center covering 5,000 to 10,000 people. Health area-specific national programs.1 The MSP directly deliv- areas are managed by a local committee (Comité de ers services through national-level tertiary hospitals, and Développement de l’Aire de Santé, CODESA) that brings advises and supports provincial and operational organi- together 10 local leaders—including the zonal medical zations (health zone and health area) to deliver health officer—to identify health needs, manage health centers, care at lower-level public facilities. and organize community activities (MSP 2016; Barroy et al. Provincial health divisions (DPS) organize and manage 2014; Secrétariat General du MSP 2006). primary health care through provincial hospitals and lower-level clinics. Provincial health inspectorates (Inspec- 2.2.2  The private service delivery health sector tions Provinciales de Santé) monitor and oversee these clinics in partnership with provincial governors and min- The PNDS highlights the important role of the private isters of health. The DPS also facilitates implementation health sector in service delivery. Available data indi- of directives and policies established at the central level. cate that the private sector accounted for 46 percent In this role, they regularly interact with private providers of the DRC’s 469 hospital structures in 2017 (Figure 3). in their regions. FBOs manage or comanage with the MSP approximately 40 percent of health zones and 50 percent of all facilities in the country. These figures are estimates given the diffi- 1 These include programs to fight malaria (Programme National culty of collecting accurate information about the private de Lutte contre le Paludisme), acute respiratory infections sector (Barroy et al. 2014). (Programme National Infection Respiratoire Aigu), diarrhea (Programme National de Lutte contre les Maladies Diarrhéiques), The importance of the private sector varies by prov- and HIV (Programme Nationale Multisectoriel de Lutte contre le ince. In most provinces covered by this assessment, SIDA, and Programme National de lutte contre le VIH/SIDA), as the public sector has the largest number of hospital well as those to promote reproductive (Programme National de Santé de la Reproduction) and adolescent health (Programme structures, with the exception of Bas-Congo and South Nationale de Santé Adolescents). Kivu, where NGOs, including FBOs, and other private 8 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Distribution of hospital structures Figure 3.  the governance and performance of the private sector by type, 2017 by strengthening its visibility and federating all pri- vate sector stakeholders (ASPS-RDC 2017). The ASPS obtained legal authorization to operate in 2017. It cur- rently has 30 members, meets monthly, and is transi- 11% tioning its leadership. The ASPS has much to learn from other private sector federations, such as the Kenya State/Para-Statal Healthcare Federation (Box 3).The ASPS is discussed FBO/NGO more in the recommendations for Leadership and Gov- 35% 54% Other Private ernance (section 3.3). Private providers also participate in the Order of Doc- tors (Ordre des Médecins), Order of Pharmacists (Ordre des Pharmaciens), and Order of Dental Surgeons (Ordre Source: MSP 2017a. des Chirurgiens-Dentistes), which are cadre-specific, founded and regulated by law, and open to both public and private providers. They are responsible for ensur- hospitals combined outnumber public hospital structures ing members respect ethics rules and advocating for (Figure 4). the medical profession. Providers must be members In addition to the hospital level, there are 1,288 autho- of their respective Orders to practice. There is not rized (licensed) private lower-level health facilities across yet an Order of Midwives (Ordre des Sages-Femmes), the country. These facilities are concentrated in urban although the Société Congolaise de la Practice de provinces, with almost 60 percent in Kinshasa (Figure 5). Sages-Femmes has been advocating for one for several (Provinces in dark blue in Figure 5 are those covered by years. The Projet de Loi to create the Order is at the the current report.) MSP but has not been brought before Parliament. The Orders are complemented by associations, federations, Private provider associations and unions (for example, the National Association of and private sector organizations Nurses of Congo, Association National des Infirmiers du The ASPS, the private health sector alliance, is the main Congo), whose main role is to advocate for and protect organization for private providers, aiming to improve member interests. Figure 4.  Distribution of hospital structures by type and by province,* 2017 46 50 Number of Structures 36 35 40 30 18 19 19 19 14 13 15 20 11 8 9 10 9 8 10 3 4 2 1 0 0 sa e o vu al a vu al ng ng nt ha Ki Ki nt ta Co rie ns th h ie Ka rt s- i-O Or Ki u No Ba So sa Ka State/Para-State FBO/NGO Other Private Source: MSP 2017a. *Data available based on the previous administrative division with 11 provinces. I NTR ODU CTI ON TO THE PR I VATE HEALTH SECTOR IN T H E DR C 9 Figure 5.  Distribution of the 1,288 authorized private health care structures by province,* 2017 900 Number of Structures 800 762 700 600 500 400 300 200 106 78 67 65 56 42 25 100 16 9 2 0 sa e o du vu al a r al a vu eu al ng m ng nt nt ha Ki Ki un nt ie t ta Co rie rie ua ns an nd h h ie Ka ut rt s- i-O -O Eq Or Ki M Ba No Ba So i sa sa Ka Ka Source: MSP 2017g. *Data available based on the previous administrative division with 11 provinces. 2.2.3  The private pharmaceutical sector 109 authorized pharmacies are in Kinshasa, and all are limited to the major urban areas where consumers with Exact numbers in the private pharmaceutical sector are more purchasing power reside. The number of unregis- unknown because of the prevalence of unlicensed and tered drug shops is not known, but nationally these are unregistered facilities. The MSP identified 30 manufac- likely to be in the tens of thousands. In Kinshasa prov- turing laboratories, 91 authorized and 171 unauthorized ince alone, the Order of Pharmacists estimates there are wholesalers, and 109 authorized pharmacies in 2017 (MSP 2017b, 2017c, 2017d, 2017e, 2017f). Most of the around 5,000. Distributors are complemented by 19 private regional distribution centers (Centrale de Distribution Régionale des Médicaments, CDRs) across the DRC, organized into a federation (FEDECAME). The CDRs supply public and Box 3.  Kenya Healthcare Federation private nonprofit facilities with pharmaceutical products The Kenya Healthcare Federation is an example of a as part of the National Supply System of Essential Drugs more advanced private sector alliance. Founded in 2004, (Système National d’Approvisionnement en Médicaments the Kenya Healthcare Federation works with private Essentiels) (ASRAMES 2016). Section 5.1provides addi- providers, hospitals, pharmaceutical manufacturers, and tional information on the size and scope of the private insurers to promote strategic public–private partner- pharmaceutical sector. ships by maximizing the contribution of the private sector. The organization conducts advocacy, PPP, net- working, and regional integration activities for members. 2.2.4  Traditional practitioners Achievements include reversing taxation on imported Information on traditional practitioners in the DRC is pharmaceutical products, participating in ministerial limited. In 2013, the MSP’s National Program for Promotion and presidential forums, and collaborating with donors, of Traditional Medicine and Medical Plants (Programme including USAID, United Nations Population Fund (UNFPA), National de Promotion de la Médecine Traditionnelle et de and the World Bank on health projects. Plantes Médicinales) undertook a census of traditional Source: Kenya Healthcare Federation, 2016 practitioners, but the results are not publicly available (Le Phare 2013). The use of traditional medicine is likely 10 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O to be high because it often is a first recourse due to the advertise cures for sterility, headaches, stomachaches, absence of modern health facilities and the cost of ser- and impotence, among others (Mayanga 2013). In 2015, vices (MSP 2016). In Lubumbashi, the number of tradi- traditional practitioners and healers formed the Union of tional practitioners is estimated to have doubled in the Traditional Practitioners of Congo (Union des Tradiprat- past five years, whereas in Kolwezi, more than 400 tradi- iciens du Congo) to encourage conformance to the MSP tional practitioners use radio, television, and signage to and WHO’s health norms (Radio Okapi 2015). I NTR ODU CTI ON TO THE PR I VATE HEALTH SECTOR IN T H E DR C 11 3.  Leadership and Governance 3.1 INTRODUCTION yet translated into widespread practice, particularly with regard to the for-profit sector. Key challenges related to The MSP is eager to further engage the private health the private health sector mentioned in MSP strategies sector, which is reflected in many of MSP’s strategies include: and policies (Box 4). Current policy emphasis on better private sector integration into the health system has not yy The private for-profit sector remains poorly known and insufficiently regulated (PNDS 2016–2020). yy Collaboration within the health sector and with other Box 4.  Key health strategies sectors, both private and community-based, is not optimized to support supply and demand for ser- yy Plan National de Développement Sanitaire (PNDS) vices or care quality (PNDS 2016–2020). 2016–2020 yy In the absence of effective quality assurance mecha- yy Plan Stratégique National Multisectoriel en Nutrition, nisms, the uncontrolled growth of the private sector 2017–2021 is a danger to the health of the population (PNDS yy Plan Stratégique National Prise en Charge Intégrée 2016–2020). des Maladies du Nouveau-né et de l’Enfant (PCIMNE), yy Private structures are weakly integrated into health 2017–2021 information systems because of insufficient contract- yy Plan Stratégique National de Lutte Contre le VIH ing (PNDS 2016–2020). et le Sida 2014–2017 yy Tensions exist between the public and private health yy Plan Stratégique National de la Santé et du Bien-être sectors (Katanga 2015–2016 Provincial Health Human des Adolescents et des Jeunes 2016–2020 Resources Development Plan). yy Plan Stratégique de la Réforme Hospitalière 2010 yy Negotiation is needed with the private sector to yy Plan Pluriannuel Complet du PEV de la République improve resource allocation and avoid dual employ- Démocratique du Congo, 2015 2019 ment (Plan Stratégique de la Réforme Hospitalière yy Plan National de Développement de l’Informatique 2010). de la Sante 2014 yy PPP expansion requires stronger regulatory measures yy Planification Familiale—Plan Stratégique National à to award contracts to private structures licensed or Vision Multisectorielle 2014–2020 certified by the government (Cadre de Planification yy Cadre de Planification en faveur des Populations en faveur des Populations Autochtones). Autochtones yy Plan National de Développement des Ressources Box 5 illustrates the progress on FP policy in the DRC. Humaines Pour la Santé 2011–2015 yy Plan Provincial de Développement des Ressources 3.1.1  Private health sector regulation Humaines de la Santé 2014–2016 Kasaï Occidental On paper, the DRC’s health sector is closely regulated. yy Plan Provincial de Développement des Ressources Relevant legislation covers the opening of health facili- Humaines de la Santé 2015–2016 Katanga ties, pricing of products and services, importing products, and establishing mutuelles. However, some regulations 12 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Box 5.  Spotlight on FP policy in the DRC The DRC’s Penal Code (dating to 1933) stipulates that any act likely to prevent conception should be penalized, including selling, distributing, exhibiting, and disseminating contraceptives. This law, which is still in force albeit largely ignored, is prob- lematic for FP service provision. The government established the National Program of Reproductive Health (Programme National de Santé de la Reproduction, or PNSR) in 2001 to address maternal mortality, FP, and related issues. Until the early 2000s, it focused more on maternal mortality than FP. With increased political pressure, the policy environment for FP has become more favorable, and in 2013, the DRC’s government presented the Declaration of Commitment to FP at the Third International Conference on FP in Addis Ababa. In 2014, the government adopted the Plan Strategique Nationale de Planification Familiale 2014–2020, the result of a year-long collaborative process among the government, local and international NGOs, religious institutions, international donors, and the private sector. Track20, the global effort to measure progress toward FP2020 goals, has developed a national composite index to rate the enabling environment for FP (NCIFP). Figure 6 shows the most recent ratings for the DRC highlight areas of progress, including the country’s FP strategy and the need for significant improvement in accountability. Figure 6.  NCIFP scores by dimension 100 80 68 54 49 49 49 60 40 23 20 0 Strategy Data Quality Equity Accountability Total Sources: Family planning in the DRC; Track20 2017 have not been updated in many years and may not be yy Direction des Soins de Santé Primaires: Oversees pri- followed. In addition, stakeholders indicated as part of mary health care in terms of information systems and the assessment a lack of familiarity with MSP regulations dissemination of policies, directives, tools, and norms. and understanding about which directorate or division yy Direction des Établissements de Soins et des Parte- to consult, highlighting inadequate integration of the nariats: Promotes participation of private health facili- private health sector in the decentralization process. ties in public health, develops policies and regulations The private health sector in the DRC interfaces with several governing all health establishments (public or private), of the MSP existing directions at central and peripheral reviews and approves contracting efforts with private levels, depending on the type of facility and location. actors, and inspects and authorizes all health facilities. The new structure outlined in the Cadre et Structures Several key stakeholders interviewed for this report Organiques from April 2017 highlights the MSP divisions indicated that private facilities outside Kinshasa deal with a role in governing the private sector, including directly with provincial and health zone level officials and may have no interface with the central level of yy Services rattachés auprès du Secrétaire Général: the MSP. Among other services, helps formalize terms of collaboration between the Ministry and civil society yy Direction de la Pharmacie et des Médicaments (DPM): organizations, NGOs, and the private sector. Oversees the quality and availability of modern and L EADER SHI P AND GOVE R NA NC E 13 traditional medicines affecting both private pharma- decentralization efforts. Participants include rep- cies and drug shops; many informal pharmaceutical resentatives from the MSP and other related minis- products bypass the direction. tries at the national and regional level, technical and financial partners in the health sector, as well as rep- yy Direction de l’Enseignement des Sciences de la Santé: resentatives from civil society. The private for-profit Oversees training of all public and private training sector is not currently included. This platform has the institutions. potential for becoming a platform for cross-sector yy Direction Laboratoire de Santé: Oversees the open- collaboration and is discussed in the Recommenda- ing and quality control of laboratories and develops tions section. protocols and policies. yy In many provinces, the Comité Provincial de Pilotage yy Direction Ressources Humaines: Responsible for the includes donors, implementing partners, NGOs, and continuing education of all health professionals FBOs, but not private for-profit providers. but focuses mainly on public-sector providers; also yy The National Pharmaceutical Commission (Commission manages the National Human Resources for Health Pharmaceutique Nationale, CPN), created by the MSP Observatory. in 2000, studies the problems facing the pharmaceu- tical and parapharmaceutical sector. The CPN includes 3.2  PRIVATE ENGAGEMENT AND PARTNERSHIPS members from the MSP, the DPM, the National Orders This section discusses forums for public–private dialogue, of Physicians and Pharmacists, the National Union of PPPs, and corporate engagement. Pharmacists, universities, and professional associations (WHO 2015). Although the CPN has not met regularly, it could be reactivated. Forums for public–private dialogue 3.2.1  in the health sector yy Sustainable Investment in Katanga (L’Investissement durable au Katanga) is a dialogue platform estab- There is growing interest in multisectoral forums to lished in 2011 to bring together mining companies, civil better engage the private sector in planning (Box 6) and society, donors, and international NGOs to discuss sus- to create opportunities for public–private dialogue, as tainable development and Katanga’s mining industry. highlighted here: yy The National Multisector Nutrition Committee yy The MSP began organizing the Comité National de (Comité National Multisectoriel de Nutrition, CNMN) Pilotage du Secteur de la Santé (CNP-SS) meetings was established in 2015 and includes an inter­ in 2017 to inform implementation of the PNDS and departmental platform and technical committee of experts. Although the CNMN is not yet functional at the national level, South Kivu and Kasai have estab- lished provincial multisector nutrition committees Interest in expanding Box 6.  (SUN 2016). public–private collaboration yy There are several dialogue platforms for universal During the assessment launch event in October 2017, health coverage (UHC), cooperatives, and mutuelles, public and private sector participants highlighted their including La Plateforme des Organisations Promo- interest in improving collaboration by integrating the trices des Mutuelles de Santé du Congo (POMUCO) private sector’s perspective into public dialogue, having and L’Union des Mutuelles de Santé du Congo. the public sector provide more support to the private Although the ASPS can serve as the interlocutor for the sector, and improving referral systems between sectors. private sector, there is not yet a strong national-level plat- Challenges mentioned included the lack of trust on both sides, the perceived poor application of the MSP’s policies form for public–private dialogue. Collaboration between and norms by the private sector, perceptions that the the public and private health sectors at the central level MSP could improve engagement with the private sector, remains weak, leading to silos and duplicative activities and lack of strong private sector governance. and structures. Although intersectoral collaboration is improving, the monitoring and implementation of 14 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O contracts remain insufficient (MSP 2016). Public–private the Vadé Mécum has not been implemented, it outlines dialogue at the district level is also inadequate. the following partnership objectives (MSP 2002): yy Integrating privately owned care institutions into the 3.2.2  PPPs for health National Health Strategy; PPPs can be a tool to accelerate development progress yy Integrating primary health care activities into private by sharing risks and responsibilities among sectors. PPPs care facilities; in the DRC are nascent, although mining companies have yy Transferring management from public medical insti- had concessions with the government for decades. The tutions to private ones; legal framework for PPPs is piecemeal, consisting of laws to regulate partnerships, approval requirements by the yy Supporting public structures through financing of Ministry of Justice, ministerial decrees for access to facil- specific activities and/or sponsorship or partial or ities, and conventions with certain partners to formalize global support; their relationship. The pending Loi sur Le Partenariat yy Supporting schools and institutes that teach health Public–Privé defines the legal framework for PPP con- sciences; and tracts in the DRC (JuriAfrique 2016). On January 9, 2018, yy Integrating private pharmacies, support to CDR, and the Ministre du Plan presented the PPP Law, previously partnerships with wholesalers. adopted by the Assemblée Nationale, to the senate, and the senate will conduct a thorough review of the 110 arti- The MSP is currently looking to operationalize the Vadé cles before voting. Priority PPP sectors include agricul- Mécum to jump-start PPPs in health. As the decentral- ture, manufacturing, telecommunications, and energy ization process continues, PPPs, mainly in the form of but not health. service agreements, would also devolve to the provin- cial and health zone levels, as has been done in Tanza- The concept of PPPs for health is not new in the DRC nia. Although the Mbanza-Ngungu Charter, a document (Box 7). In the early 2000s, the Italian and Belgian aid developed in 1984 as the basis for intrasectoral and inter- agencies and the World Bank provided financing to sectoral partnerships, it has not served a large role to explore development of PPPs and define a legal frame- date at the peripheral level and needs updating in the work. This led to development of the Vadé Mécum du context of PPPs (MSP [n.d.]b]). The Comité Technique Partenariat in 2002, which provided a framework and Multisectoriel Permanent pour le Repositionnement de defined the principles of contracting in health. Although la Planification Familiale en RDC (CTMP) is a promising forum at both the central and provincial levels (Box 8). Jason Sendwe Hospital— Box 7.  a PPP example in Lubumbashi Comité Technique Multisectoriel Box 8.  Permanent pour le Repositionnement In 2004, with the help of the Belgian Aid agency, manage- de la Planification Familiale en RDC ment of Jason Sendwe Hospital in Lubumbashi (managed by Gecamines since 1974) was transferred to the Univer- The CTMP is a government-led initiative operating at the sity of Lubumbashi. A hospital management convention central and provincial levels. In March 2015, the prime was signed between the MSP and the University, whereby minister endorsed the CTMP, raising its visibility. The the government retains control of the facility, and the CTMP currently operates in 12 of the 26 provinces, with University manages the 1,200-bed hospital in conjunction plans to scale up to all provinces. The CTMP has suc- with the Congolese government and the province. In 2015, cessfully engaged the private sector, raising funds from the facility received operating room equipment from the private companies for FP services and partnering with Gertler Family Foundation. Vodacom and Orange to provide health messages that Source: Gertler Foundation 2014; Dikembe Mutombo Foundation can include FP. Callers receive 10 free health messages 2017. and then pay a fee to the telecom provider. L EADER SHI P AND GOVE R NA NC E 15 Current organizational structure for health PPPs Health zones with FBO reference Figure 7.  The Direction des Partenariats was established in 2003 hospitals, 2016 to ensure proper management of partnership-related data at all health system levels and technical support and coordination with internal and external partners (see Box 9 for an example of an existing PPP) (MSP 2013). A reorganization of the MSP is under way, in which the Direction des Etablissements des Soins et Partenariats will manage partnership activities. The Direction currently manages donor projects and contracts for health zone and facility management with each major religious group—Catholics, Protestants, Kimbanguists, and Muslims (see Figure 7 for the sta- tus of health zone with FBO reference hospitals) (U.S. Department of State 2011). The Direction manages the contract review and implementation period, usually lasting three to five years (and up to 25 years). The MSP retains control of structures, whereas FBOs manage Protestant staff and pay for equipment and facility investments. Catholic The following challenges regarding PPPs were identified in a workshop supported by the Italian Aid Agency in 2011 and still persist: Source: Baer and Sambu 2016. yy Insufficient monitoring, evaluation, and coordination of externally funded projects; yy Inadequate alignment between donor projects and yy Information and communication deficits within the government priorities, with projects implemented MSP, especially at the central level; without informing provincial and central level MSP leaders; yy Poor government control over the financial flow or Box 9.  PPPs in action in South Kivu management of external aid; yy Confusion about partnership management and pro- The Catholic Church created the Bureau Diocésain des motion, leading to overlapping responsibilities rather åuvres Médicales (BDOM) in South Kivu to facilitate collabo- than intrasectoral and intersectoral collaboration; and ration with the MSP and manage the Church’s health struc- tures and pharmaceutical depot. By 2012, the Ministry had yy Insufficient development of public–private approaches contracted BDOM Bukavu to manage 12 health districts. with the potential to contribute toward increased cov- BDOM was responsible for improving administrative man- erage of services (Direction de Gestion du Partenariat agement of the facilities, increasing access to and quality pour la Santé n.d.). of services, reinforcing the capacity of the District Executive Team (Equipe Cadre de District), and mobilizing resources 3.2.3  Corporate engagement to support districts. The partnership led to improved health outcomes and public–private collaboration while also Corporate engagement, in which resources and expertise strengthening the state’s credibility and reach. Weaknesses from the corporate sector help advance social goals, can included the lack of government compliance regarding be mutually beneficial to companies and governments. The commitments made for exemptions and personnel salaries. corporate sector, donors, and governments benefit through Source: Mushagalusa 2014. access to complementary technical expertise in areas such as supply chain, access to new technologies, and the ability 16 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O to take solutions to scale. For corporates, it is critical that partnerships not only promote the public good but also Box 11.  Banro’s contributions to DRC benefit business and align with corporate brands. Current regulations in the DRC require companies to make Banro invested US$492 million in South Kivu and Maniema provinces and employs over 1,000 people in technical, pro- social investments related to their business (Jansson 2010). fessional, management or supervisory roles, with another Additionally, companies are increasingly motivated by 3,000 employed through contractors, generating another consumer demand, whereas international companies face 20,000 jobs indirectly, and ultimately supporting over increased pressure to demonstrate social responsibility 200,000 Congolese. The Banro Foundation upgrades and (Cone Communications 2017). For example, recent trends constructs new roads, housing, health facilities, and pota- demonstrate heightened consumer demand for supply ble water systems. The Foundation has built 10 new schools, chain transparency, especially for minerals sourced from rehabilitated two existing schools, and provided vocational DRC. Although companies such as Microsoft and Apple training and skills development to its employees. may not have a business presence in the DRC, they pur- Source: ResolutionPossible 2013. chase Congolese cobalt for the production of electronics, and public pressure has influenced their implementation of programs with social goals. Likewise, companies such as GlaxoSmithKline (GSK) are under increased consumer companies also support community health efforts. For pressure to ensure their products contribute to advancing example, Qualcomm purchases many Congolese com- positive health outcomes and access to services. modities for their electronic products and supports the development and delivery of educational materials for The mining sector miners about health risks and the signs of respiratory diseases, including tuberculosis. Mining companies with a Mining contributes almost one-third of the DRC’s GDP local presence also support health programs for their staff and includes mining companies, logistics and security and local communities. For example, the mining company companies, as well as companies that purchase mined Banro supports health care facilities for its workers and commodities (for example, copper, cobalt, and lithium) the surrounding community and upgrades to infrastruc- (CIA n.d.). Companies such as Microsoft and Apple mainly ture, such as roads and water (Box 11). fund programs for environmental protection or the pre- vention of human trafficking and child labor, such as Health care companies the Mines to Markets Program supported by Microsoft, General Electric, and Boeing through Pact (Box 10). Some International pharmaceutical and device manufacturers support market research and social programs in the DRC, even without a local presence. Their motivation is to sup- port a positive brand association with social good on a Box 10.  Mines to Markets Program global scale, as well as product development and new market growth. For example, GSK is currently conducting Microsoft, General Electric, and Boeing support programs its own assessment of the pharmaceuticals market related to prevent child labor by addressing factors that attract to respiratory infections (both pneumococcal vaccines children through the Pact Mines to Markets program. and antibiotics), which is critical for product expansion by Together, they support programs to raise awareness of GSK in the DRC. These efforts are critical to improving the children’s rights, improve the capacity of local orphan- accessibility of quality care in low-resource environments ages, and support home-based day care for younger children. While these programs do not currently include a and also to understanding how programs can be imple- health focus, there are opportunities to include informa- mented effectively with private sector partners. tion for caregivers about malaria, nutrition, pneumonia, Medical device manufacturers also invest in product and diarrhea, thereby leveraging corporate investment to design for low-resource environments to both create improve child health. new markets and advance health goals. For example, Source: Pact n.d. as part of their vision for “health care without bounds,” Phillips has developed a new product designed to improve L EADER SHI P AND GOVE R NA NC E 17 Recommendation: Undertake a legal and regulatory review Philips Community Life Centers Box 12.  to help identify legislative and regulatory bottlenecks in Kenya related to private health service and product delivery using a participatory process to ensure buy-in and prior- Results from Kenya are tremendous. Within the first itization of the most urgent changes needed. 18 months of the CLC opening, the total number of out- patient visits per month increased from 900 to 4,080. 3.3.2  Public–Private Dialogue For children, this number quadrupled from 533 to 2,370. For antenatal care, the number grew 15-fold, from 13 to Support the ASPS to assume a stronger leadership role 188 patients per month, with the number of fourth visit within the private sector and with the government antenatal care patients each month growing 16-fold, Finding: ASPS is a fledgling private sector umbrella orga- from six to 94. nization, which is unclear of its role and does not have a Source: Philips n.d. formal platform to interact with the public sector. Poten- tial roles include overseeing compliance of quality norms for member organizations, connecting private providers health access in rural areas of DRC. to UHC initiatives, serving as a clearinghouse on financing The product is called Community strategies for private providers, and helping increase con- Life Centers (CLCs) and has just tracting opportunities with the MSP. An important compo- launched in Tadu in northeastern nent of the ASPS’s ability to represent the private health DRC. The CLC offers vital primary sector is that its constituency represents a cross-section of health care services using Phillips private sector stakeholders. As a convening entity for the products, including a fetal Doppler private health sector, it can offer a much-needed venue for that can be used to detect infant industry groups and professional bodies to debate import- heartbeats during routine antena- ant issues and an avenue for government and donors to tal visits and delivery. The CLCs engage with the private health sector. At the provincial and are designed to be a community district levels, the ASPS can advocate for private sector hub where technologies are bundled to provide access interests and collaborate on health initiatives. to health and social services (Box 12). The availability Recommendations: of products designed specifically for contexts such as yy Strengthen the ASPS’s capacity to fulfill its role as the DRC may present new opportunities for PPPs. an effective interlocutor for the private health sector by conducting an institutional analysis and bench- 3.3 RECOMMENDATIONS marking to assess its financial, programmatic, and This section highlights recommendations for the MSP and organizational performance and needs and using the donors on regulating the private sector, private engage- results to develop a tailored capacity-building plan. ment, and partnerships and corporate engagement. yy Develop a dynamic advocacy plan and agenda for the ASPS consistent with its core mission and backed 3.3.1 Regulation by member consultation and a consensus-building Conduct a legal and regulatory review to identify process. regulatory articles needing reform related yy Undertake a review of ASPS membership to identify to the private health sector constituencies lacking representation, such as com- Finding: There is confusion about how current legislation panies with worksite clinics, and establish a growth affects access to private health services and pharmaceuti- plan to ensure the ASPS’s membership represents cals. The World Bank in Senegal and USAID in Côte d’Ivoire the entire private health sector, not just private health have helped identify legislative and regulatory bottlenecks providers. related to private health service and product delivery to yy Develop a resource mobilization plan to increase pave the way for more efficient private health delivery. ASPS’s long-term financial sustainability, identifying 18 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O potential public and private sources of financing from yy Evaluate the potential to structure a risk mitigation financial institutions, the government, donors, profes- instrument, such as a mutual guarantee fund, that sional bodies, and industry groups, as well as through would be available to members of the ASPS who meet membership fees, in-kind contributions, fund-raising, minimum requirements. training and services revenue, and conference fees. yy Establish regional ASPS branches to address health Launch national- and district-level public–private priorities in each region. dialogue forums yy Ensure the ASPS aligns with the West Africa Health- Finding: As remarked by the minister of health at the care Federation and the Africa Healthcare Feder- assessment launch in October 2017, there is a need for ation to accelerate learning and participates in the a cadre de concertation for the private for-profit health planned Central Africa Federation to build on private sector to meet regularly with the public sector to resolve sector initiatives in the region. challenges and collaborate. Based on lessons from Abt’s work in Côte d’Ivoire, Benin, and Senegal, the private Leverage and build the capacity of ASPS to add value sector is motivated by the prospect of a greater role in to the private health sector decision making and partnerships. A strong forum for public–private dialogue enables the private sector to Finding: The ASPS could be a valuable partner in expand- advocate with a unified voice, strengthens PPPs, and leads ing financing for the private health sector. to a stronger, more organized, and better-coordinated Recommendation: Work with and build ASPS’s capacity health sector. to conduct the following activities: Recommendations: yy Manage the logistics for provider business training yy Establish or repurpose a small technical committee sessions; at the national level to meet monthly or quarterly yy Carry out training of trainers to increase training (depending on stakeholder interest), with the ASPS availability and sustainability; representing the private for-profit sector, and includ- yy Develop guidelines and checklists for providers ing other representatives, such as FBOs. Potential to understand regulatory requirements to maintain topics for the national forum include streamlining the their professional accreditation and ensure that their current registration process, private sector reporting, health care businesses are properly registered, facil- quality standards, and collaborative opportunities itating health providers’ access to formal financing; for training in service delivery, business, and finan- yy Maintain a member database that financial institutions cial management. Two existing platforms that could could consult to verify licensing/certification status of be repurposed are the CTMP and the CNP-SS. The health providers wishing to borrow from the financial CTMP, which brings together public-sector staff and institution; private companies to focus on funding FP activities, could expand beyond FP to other health areas and yy Provide general information about the private health include private providers. The CNP-SS, which cur- sector and facilitate training for financial institutions; rently focuses on decentralization of the public sec- yy Offer a forum for financial institutions and private tor, could add a private sector voice and potentially providers to discuss concerns; serve as the public–private platform at the national yy Organize trade fairs to connect health providers and provincial level. Additional review is needed to to financial institutions and other business input determine whether the CTMP or CNP-SS could serve suppliers; as a public–private dialogue vehicle. yy Support sectoral studies on topics such as how to yy Establish or repurpose public–private dialogue forums improve the supply and maintenance of medical at the health zone level to strengthen private sector equipment in the DRC or identifying specific financ- representation and reporting, resolve issues, and share ing needs of female providers or FBOs; and resources, learning from efforts in other countries. L EADER SHI P AND GOVE R NA NC E 19 In Yamoussoukro, Côte d’Ivoire, the health district capacities needed at the central and peripheral levels. leadership created a public–private forum to better yy Develop a preliminary list of PPPs to consider— integrate private providers in the health information potential PPP opportunities include the Clinique system and engage the private sector in achieving Kinoise in Gombe, Kinshasa; mining and railroad hos- public health goals. The USAID-funded Strengthening pitals in Katanga region; the Katana Hospital in South Health Outcomes through the Private Sector (SHOPS) Kivu and Bas Congo; health facilities affiliated with project documented the experience in a case study Perenco; the Société Congolaise des Industries de and trained all regional- and district-level health offi- Raffinage; and cement production. MSP could work cers in the country on the Yamoussoukro model. With with partners such as the IFC, which has extensive SHOPS’s assistance, districts launched public–private experience providing technical assistance to gov- dialogue platforms with road maps for activities to ernments to support the formation of health PPPs. guide future public–private collaboration (SHOPS For example, in Lesotho, IFC helped the government Project, 2016). develop an 18-year PPP agreement with Tsepong, a local health care company operating a private hos- Support the establishment of an Order of Midwives pital and clinics, to develop a network of PPP clinics with more-advanced medical technologies, support- Finding: Currently there is no Order of Midwives in the ing better health outcomes for a larger number of DRC, which means there is no coordinating body to ensure public-sector clients. midwives are trained, can access continuous education, or are meeting quality standards. The Société Congolaise de la Practice de Sages-Femmes has been advocating for Build the MSP’s capacity to better leverage PPPs several years for a Midwife Order, similar to other cadres. and private sector investment By the end of 2017, the arrêté (decree) to make the Asso- Finding: During the ongoing MSP restructuring, the ciation into an Order was pending signature at the MSP. role of the Direction des Établissements de Soins et des Recommendation: Identify a champion within MSP to Partenariats is unclear, particularly the role of the Division support establishment of an Order of Midwives. Specif- de Partenariat et Contractualisation. Given the growing ically for FP, the Order could increase sensitization and importance of PPPs, there is a need to create a high-level promote FP, distribute short- and long-term contracep- private sector cellule (unit) at the Secrétaire Général level tive methods in partnership with UNFPA, and dissemi- and also clarify the responsibilities of the Division de nate good practices. Partenariat et Contractualisation. Recommendations: 3.3.3  Partnership Strategy yy Create a private sector cellule as the first contact Develop a health PPP strategy to guide within the MSP to accompany the development and MSP’s partnership activities integration of the private sector and promote the Congolese health sector to attract new investors. This Finding: Currently there is no health PPP strategy, although cellule could report directly to the Secrétaire Général there is the pending Vadé Mécum du Partenariat, which with a line to the minister of health and a dotted line focuses on financing modalities for PPPs. to the Cabinet to have access to decision makers and Recommendations: the requisite autonomy. yy Develop a PPP strategy for health aligned with the yy The new Division de Partenariat et Contractualisation Vadé Mécum du Partenariat and with the following could oversee contracting with the private health elements: general PPP framework, PPP definition, insti- sector, donor coordination, and PPPs (Figure 8). It tutional coordination and responsibilities, identifica- should liaise with the National Agency for Investment tion of potential projects and award procedures, and Promotion for larger PPP projects and with regions agreement template. The PPP strategy will also need and health zones for smaller PPPs and serve as a to describe the planned decentralization of PPPs to focal point within the MSP for updated and accurate the health zone level and the roles/responsibilities and information on the private health sector. 20 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Figure 8.  Role of the PPP Unit within the MSP Identify PPPs and support PPP Serve as interface with Donor coordination implementation private health sector Contract with nonprofit and Build PPP capacity and oversee Monitor and evaluate PPPs for-profit sectors PPP strategy development Move forward with finalizing the FBO convention Recommendation: Work with pharmaceutical and medical device companies to bring and/or scale up new products Finding: FBO conventions are piecemeal, with each that improve access to and delivery of health services. faith community negotiating contracts separately and for different time periods. This can lead to favoritism, lack of transparency, and unfairness. There has been Partner with companies piloting and developing much discussion about the need for a uniform conven- technologies with potential application tion so all FBOs receive the same treatment and have in the health system the same terms with the MSP. Finding: Companies are increasingly developing prod- Recommendation: Facilitate dialogue to bring the ucts using new technologies, such as block chain, that can negotiations to a close and obtain approval for a stan- strengthen programs across the health system. For exam- dardized convention for all FBOs that contract with ple, MasterCard works in many countries, including those the MSP. with poor infrastructure such as Yemen or rural Nigeria, to improve the delivery of social services. Its products, such Collaborate with pharmaceutical and medical as MasterCard Aid Network, use block chain to mobilize device companies to improve access financial resources for refugees more efficiently while also to and delivery of health services reducing risk and empowering refugees to make their own decisions. Technology companies can help determine the Finding: International pharmaceutical and medical device latest application and use of products to capture efficien- manufacturers support market research and various social cies, reduce risk, and improve access. programs in the DRC, even without a local presence. Gov- ernment and donors could consider working with compa- Recommendation: Consult with technology companies nies to ensure their products become available in the DRC. when considering the implementation of new programs By working with such companies, DRC is more likely to and/or reforms across the health system, especially when become a country where these companies elect to design designing solutions to improve product tracking, phar- and/or user test new products. macovigilance, and/or vouchers. L EADER SHI P AND GOVE R NA NC E 21 4.  Service Delivery 4.1 INTRODUCTION The private health sector is an important source of health The role of social marketing Box 13.  care across the DRC. For-profit providers are concen- franchises in DRC trated in urban areas, but FBOs and NGOs, often sup- The Association de Sante Famiale (ASF)’s Confiance fran- ported by donors, typically operate in underserved areas. chise network, developed to deliver FP services, was the Together these facilities operate at all levels of the health first of its kind in the DRC. Its service offering has since system and offer a broad range of services. The private expanded to include the prevention and proper man- sector accounts for 44 percent of outpatient care and agement of diarrhea in children younger than 5 years as 25 percent of inpatient care in the DRC (Wang et al. 2016). well as malaria interventions where the necessary com- Eighty percent of facilities offering basic surgery are modities are available. ASF’s network comprises 116 clin- private (MSP 2014b). Private facilities score higher than ics and health centers. In 2015, these facilities received public in operational capacity at 41 percent and 18 percent, 74,821 visits, averted 31,724 disability-adjusted life years, respectively (MSP 2014a). On average, private facilities, and provided 17,619 couple years protection. Most of the including for-profit, FBOs, and NGOs, are more likely to franchise’s clients come from the richest quintiles. have basic infrastructure (for example, access to electric- Source: Viswanathan et al. 2016; Chakraborty 2013. ity, clean water, and sanitation services, communication equipment) and essential medicines (Figure 9) than are public facilities. However, most facilities in both sectors services. Government efforts to better integrate private are still likely to lack access to these inputs. facilities with the larger health system have been limited. Private facilities largely operate on an independent basis, The increasing verticalization of health programs, exac- and often lack training, qualified personnel, equipment, erbated by donor funding streams, makes it challeng- supplies, salaries, or incentives to provide high quality ing to develop and implement multi-pronged activities Figure 9.  Availability of medicines and products in health facilities by type of service and sector 100% Percent of Health Facilities 80% 69 66 63 49 57 55 55 50 60% 45 40 43 37 38 40% Public 30 Private 20% 0% Emergency Child health Adolescent Tuberculosis HIV/AIDS Antiretroviral Malaria obstetrics services health services Source: MSP 2014a. 22 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O involving the private sector. Donors currently partner The overall contraceptive prevalence rate (CPR) is stag- with some private actors—mainly in the FBO and NGO nant, remaining at about 20 percent of married women sector—to distribute free or low-cost FP products and between the 2007 and 2013–14 DHS. Among modern trainings. However, these programs are not coordinated method users, short-term methods—primarily condoms— with larger efforts; a recent assessment of the FP market dominate. The method mix shifts with age, as older users found that though there are several international donors tend to use long-acting and permanent methods, espe- and partners distributing free or low-cost FP products cially sterilization (Figure 11). and providing training, supplies are inadequate and sporadic and there is no organization or coordinating 4.2.2  Service delivery dynamics body for these efforts (UNFPA 2017a). This lack of inte- gration often crowds out private for-profit actors who do Availability not participate in these efforts. Some private for-profit Only 32 percent of private facilities have FP services avail- stakeholders interviewed stated that they do not offer able, including a room for FP service provision and staff certain products and services because they are not will- trained in FP (MSP 2014a). Although service availability ing to compete with free options offered by donors and is low, quality is rated highly relative to the public sector, their partners. with clients citing shorter waiting times and less frequent stockouts (Mpunga et al. 2017). Private clinics associ- ated with implementing partners, such as the Association 4.2  FAMILY PLANNING pour le Bien-Être Familial (ABEF, an International Planned 4.2.1 Context Parenthood Federation affiliate) or Population Services The DRC’s Family Planning National Multi-sectoral Strate- International (PSI), are more likely to offer the full range gic Plan 2014–2020 formalized the objective of increasing of FP services and products. Although ABEF operates mCPR for all women of reproductive age to 19 percent by only five clinics, it has 146 partner clinics (public and 2020 (MSP 2014b. Increasing access to FP products and private) to which it provides free FP products and train- services is important as the DRC seeks to address its high ing. Association de Santé Familiale (ASF), a PSI affiliate, maternal and child mortality rates, but current mCPR in runs a social franchise called Confiance that primarily the DRC is among the lowest in the region (Figure 10). provides FP services through its 133 clinics. In addition, Figure 10.  Use of modern contraceptive methods in the DRC and other countries Benin 2011-2012 8% DRC 2013-2014 8% Nigeria 2013 10% Equatorial Guinea 2011 10% Niger 2012 12% Cameroon 2011 14% Sierra Leone 2013 16% Togo 2013 17% Burundi 2010 18% Liberia 2013 19% Gabon 2012 19% Congo 2011-2012 20% Uganda 2011 26% Rwanda 2010 45% Zambia 2013-2014 45% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Source: DHSs, date depending on national data availability (Barroy et al. 2014). SERVI C E DE LIVE RY 23 Figure 11.  Modern contraceptive method mix by age 100% 7% 10% 11% 12% 7% 5% 5% 7% Women, 15-49, Using a Modern 6% 15% 80% 8% 7% 7% 10% 9% 9% Contraceptive 60% 50% 11% 13% 10% 40% 17% 74% 4% 52% 5% 57% 5% 20% 35% 21% 0% 15-24 25-34 35-44 45-49 Total Condom Injections Pill Implant IUD Sterilization Other modern Source: DHS 2013–14; Avenir Health 2017. ASF socially markets a variety of contraceptives under Source of methods the Confiance brand (Family Planning in the DRC 2017). Private facilities that are not affiliated with a donor or In line with perceptions about FP service quality, private implementing partner are less likely to offer FP products outlets are the main source of modern FP methods. Pri- and services, in part because they view FP as not com- vate facilities, pharmacies, and shops serve 60 percent mercially viable. Some FBOs, particularly Catholic facili- of modern method users (DHS 2013–14). Compared with ties, do not officially offer FP services, but clinicians who other countries in the region, such as Rwanda or Senegal, work there may bring and sell FP products and services in the DRC the role of the private sector is particularly or refer clients to nearby facilities with FP services. important (Figure 12). Figure 12.  Regional comparison of source of FP methods DRC Rwanda Tanzania Nigeria 5% 40% 72% 60% Benin Senegal Private (including shops) Other 12% 45% Public Missing Source: DHS 2013–14; SHOPS Plus 2017. 24 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Figure 13.  Family planning source by wealth quintile 500 408 400 Users of modern contraception Thousands 300 225 200 149 133 79 79 98 60 53 63 100 39 21 10 17 22 0 Poorest Poorer Middle Richer Richest Public Private (including NGOs & shops) Church, friend, other Source: DHS 2013–14; Avenir Health 2017. The private sector is an important source of contracep- more evenly split between short-term and long-acting or tives across all wealth quintiles, although the public– permanent methods (Figure 14). private split is less pronounced among poorer populations (Figure 13). Youth Pharmacies and drug shops account for over 70 percent Youth and adolescents (15–24 years) are more likely of all privately sourced modern contraceptives. All health to obtain FP from a private source, whereas older age facilities combined (hospitals, clinics, and health centers) groups (35–49 years) are more evenly split between account for approximately 15 percent of the private sec- public and private sectors (Figure 15). This trend reflects tor’s market share. The remainder is a mix of NGOs, mobile the types of methods used—younger people are more outreach, and shops (DHS 2013–14). In line with the reliance likely to use short-acting methods, which they can on pharmacies and drug shops, users of private sector procure from a shop (for example, condoms), whereas services are more likely to access short-term methods that older women are more likely to use an FP service that do not require a clinical service (for example, condoms, includes a clinical component and must be delivered at oral contraceptive pills), whereas public-sector users are a health facility. Figure 14.  Contraceptive methods by source 1,000 41 Users of modern 800 contraception Thousands 600 400 829 194 200 259 131 0 Public Private (including NGOs & Church, friend, other shops) STM LAPM Source: DHS 2013–14; Avenir Health 2017. SERVI C E DE LIVE RY 25 Figure 15.  FP source by age 500 395 400 323 Users of modern contraception Thousands 300 184 161 152 200 107 100 66 43 23 0 15–24 25–34 35–49 Public Private (including NGOs & shops) Church, friend, other Source: DHS 2013–14; Avenir Health 2017. About half of private providers surveyed in Kinshasa assessment (Figure 16). FBOs are significant contributors and Kongo Central (Matadi) (52 percent and 51 percent, in South Kivu. Overall, the private sector serves just less respectively) offered FP counseling to adolescents (Per- than half (46 percent) of new FP users across these eight formance Monitoring and Accountability 2020 [PMA2020] provinces. Service provision for renewing FP users fol- 2017; 2017a). lows a similar pattern, with the private sector serving just over half (52 percent) of renewing users. Regional FP dynamics According to DHIS2 data, private hospitals, health cen- Spotlight on private FP service provision ters, and health posts in 2016 served three-quarters of in Kinshasa and Kongo Central (Matadi) new FP users in Kinshasa and Kasai Oriental provinces, Contraceptive use in Kinshasa was low in 2017—only half of new FP users in Lualaba, and less than 50 per- 22 percent of women reported using a modern contra- cent of new users in the other provinces reviewed in this ceptive method (PMA2020 2017). Contraceptive use in Figure 16.  New FP users in 2016 100 95 New FP Users (in Thousands) 80 67 63 54 Public 60 45 FBO 36 40 30 26 29 28 Other Private 20 19 16 20 9 10 6 5 8 5 4 3 4 0 0 0 Kinshasa Kasa Haut Lulaba Kongo Tshopo Sud Kivu Nord Kivu Orientali Katanga Central Source: MSP 2018. 26 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Kongo Central is even lower and falling; modern method According to 2017 data, 68 percent of private facilities use decreased from 20 percent in 2015 to 17 percent in in Kinshasa and 62 percent of private facilities in Kongo 2017 (PMA2020 2017). Central offered FP services. Both cities are comparable According to a mapping of all FP service delivery sites in the number of days facilities are open (5.7 in Kinshasa; conducted by Tulane University in 2013, few facilities in 5.4 in Kongo Central) and in some of the services they Kinshasa were adequately prepared to deliver FP services. offer. User fees are charged by more private facilities in As shown in Figure 17, FP products are more commonly Kongo Central (31.7 percent) than in Kinshasa (11.6 per- available in pharmacies (small dot with bullseye) than cent) (PMA2020 2017). Data for 2017 are not available formations sanitaires (large dot). The abundance of red for other cities in this report. compared with green dots reflects that most facilities Although private facilities in Kinshasa reported chal- that are supposed to offer FP services do not have trained lenges with frequent stockouts, they were more acute staff or methods (other than condoms) available. for short-acting methods, such as male condoms, pills, Figure 17.  Pharmacies and facilities offering FP in Kinshasa, 2013 Source: Bertrand 2014; Family Planning in the DRC. SERVI C E DE LIVE RY 27 Figure 18.  Percent of private facilities in Kinshasa offering FP with methods in stock on day of interview 100% 17% 13% 30% 5% Private Health Facilities 80% 51% 16% 15% 58% 65% 4% 60% 16% 7% 40% 10% 6% 6% 63% 67% 55% 20% 36% 31% 28% 0% IUDs Implants Depo-Provera Sayana Press Pills Male Condoms In stock and no stockout within 3 months In stock, with stockout in past 3 months Current stockout Not offered Source: PMA2020 2017. and Depo-Provera injectables. Fewer facilities reported 4.3  MATERNAL HEALTH commodity stockouts for long-acting methods, possibly 4.3.1 Context because they were less likely to offer these services (Figure 18). Maternal mortality has increased in the DRC from The percentage of private facilities with Sayana Press 549 deaths per 100,000 live births in 2007 to 846 in 2014 (5 percent), intrauterine devices (22 percent), implants (MPSMRM, MSP, and ICF International. 2014). In addition, (22 percent), and Depo-Provera (49 percent) was low 35 percent of all female deaths were attributed to mater- (see Figure 19) (see Box 14 for information on pilot task- nal causes (up from 19 percent in 2007). These statistics sharing program for Sayana Press). Private facilities were reflect the impact of war and ongoing violence, which more likely to stock short-acting methods, such as pills and have slowed post-conflict rebuilding of the health system male condoms (54 percent and 59 percent, respectively). and exacerbated gender-based inequities. In response, Figure 19.  Percent of private facilities in Kongo Central offering FP with methods in stock on day of interview 100% 22% 17% Private Health Facilities 80% 34% 12% 15% 60% 73% 73% 12% 10% 17% 95% 40% 2% 54% 59% 20% 5% 49% 22% 22% 5% 0% IUD Implants Depo-Provera Sayana Press Pills Male Condoms In stock and no stockout within 3 months In stock with stockout in past 3 months Current stockout Not offered Source: PMA2020 2017a. 28 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Leveraging task sharing to improve access to Sayana® Press Box 14.  A 2015 pilot in Kinshasa assessed acceptors’ attitudes toward both Sayana® Press as a contraceptive method and com­ munity-based distribution by medical and nursing students, known locally as “DBCs.” Sayana® Press acceptors expressed high levels of satisfaction with the method. Although most were satisfied with the counseling and services received, less than one-third realized that the community-based distributors were students. The distributors expressed satisfaction in their role, with over 95 percent stating they would recommend it to others. Their primary complaints were lack of remuneration, stock- outs, and need for greater supervision. The pilot validated the use of students in community-based distribution, paving the way for additional task-shifting pilots in Kinshasa. Source: Bertrand, et al. 2017 the MSP highlights maternal health as an important com- ponent of the PNDS and in the new Stratégie Intégrée pour la Santé de la Femme, de l’Enfant et des Adolescents 2017–2020, which is still under development. 4.3.2  Service delivery dynamics Most live births occur at a public facility, whereas 16 per- cent occur in a private facility (DHS 2013–14). Despite this variation, the DRC’s use of the private sector for births is higher than that of other countries in Central and West Africa (Figure 20). The private sector could contribute more to maternal care, especially prenatal care and emergency obstetric services to reduce maternal mortality (Ntambue et al. 2016). The 2014 WHO Service Availability and Readiness Assessment (SARA) found that—compared with public Figure 20.  Place of live births 100% Percent of Live Births 80% 60% 40% 16% 20% 14% 8% 12% 4% 3% 0% DRC Ghana Liberia Mali Nigeria Senegal Public Private Home Other Source: DHS Program. n.d. SERVI C E DE LIVE RY 29 facilities—private facilities were more likely to have key Nouveau-né et de l’Enfant 2017–2021 highlights dis- inputs for maternal health services, such as antenatal parities in coverage among various child health services care guidelines; clinicians trained in antenatal care and components and geographic areas. In response, strat- delivery; and relevant equipment, tests, and commodities egy objectives include strengthening provider capac- such as antibiotics and iron and folic acid tablets. ity; increasing the percentage of health trainings with IMNCI; scaling up family- and community-based IMNCI 4.4  CHILD HEALTH practices in all 26 provinces; improving the availability of IMNCI drugs; strengthening management of IMNCI 4.4.1 Context data; and ensuring coordination of IMNCI at all levels of The DRC adopted the integrated management of neo- the health system. natal and childhood illnesses (IMNCI) strategy in 1990. This approach focuses on the total well-being of the child 4.4.2  Service delivery dynamics to accelerate reductions in under-five mortality. IMNCI incorporates prevention and management of the leading The private sector is an important source of care for causes of death, including pneumonia, malaria, diarrhea, sick children (see Box 15). Among caregivers who seek malnutrition, anemia, HIV/AIDS, and neonatal disorders. sick child care outside the home for fever, acute respira- A review of IMNCI implementation in the Plan Stratégique tory infection, or diarrhea, 44 percent sought treatment National de Prise en Charge Intégrée des Maladies du or advice from the private sector (Figure 21). Most go to Box 15.  Private sector capacity building for child health Most caregivers seeking treatment for childhood illnesses access private sector drug shops. However, knowledge of child illness case management among drug shop staff is extremely limited. A two-year pilot program (2009–11) in Kinshasa evaluated the knowledge and practices of counter agents in private pharmacies regarding the management of childhood diseases (respiratory illness, malaria, and diarrhea). Private pharmacy employees were trained and received supportive supervision in line with national policies and guidelines in counseling, dispensing, and referrals. As part of this effort, implementers examined drug dispensing practices and behaviors related to IMNCI, as well as the systemic factors supporting these practices (for example, supply chain capacity, availability of essential medicines for childhood illnesses, and ability of key actors to iden- tify challenges and success factors in health systems strengthening processes). Pilot results reflected improved knowledge of danger signs across the board. Between 2009 and 2011, surveyed agents saw the following improvements: yy Did not know any signs of severe respiratory illness or knew only one reduced from 36 percent to 16 percent and from 49 percent to 33 percent, respectively; yy Knowledge that honey can be used for colds/coughs increased from 0 percent to 72 percent; yy Could recommend the correct treatment for pneumonia increased from 27 percent to 61 percent; yy Advised ORS + ZINC to manage diarrhea increased from 4 percent to 75 percent; yy Identified fever as a sign of malaria rose from 83 percent to 97 percent; and yy Knowledge of artesunate-amodiaquine increased from 22 percent to 72 percent. Lessons learned reflect that private pharmacy staff are capable of dispensing medicines for the treatment of respiratory illnesses, malaria, and diarrhea by drawing on their knowledge and referring to national policies. Over the course of the pilot, almost 5,000 cases (children ages 0–5) were treated in 1.5 years, suggesting that the intervention could be useful in address- ing infant mortality and behavior change in parents. Gaps in knowledge persist. The assessment team found that when asked how to take a zinc and ORS copack, drug shop staff frequently provided incorrect instructions, even when they had a concise instruction leaflet accompanying the copack product. Source: SPS 2011. 30 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Figure 21.  Source of child health care in the DRC nonclinical sources, such as pharmacies, shops, or markets (81 percent), whereas fewer than one-quarter go to a pri- vate clinical facility, such as a hospital, doctor’s office, or clinic (Bradley et al. 2017). The private sector’s role in the provision of child health services is significant across all wealth quintiles, from 40 percent in the lowest wealth quintile to over 60 per- cent in the richest (Figure 22). This importance for lower-income households is more pronounced in the DRC compared with other countries in the region, second only to Nigeria (Figure 23). Source publique Source privée Les deux Autre Most private providers (84 percent) offer preventative Source: Bradley et al. 2017. and curative child health services (MSP 2014a). While Figure 22.  Source of child health care by wealth quintile 100% which Care was Sought 80% Incidences of CH in 36% 39% 40% 46% 60% 65% 40% 20% 0% Poorest Poorer Middle Richer Richest Public only Private only Both public and private Other only Source: Bradley et al. 2017. Figure 23.  Source of child health care for the lowest wealth quintile in select sub-Saharan African countries Senegal 12% Nigeria 61% Public Mali 33% Private Liberia 36% Both Ghana 30% Other DRC 39% 0% 20% 40% 60% 80% 100% Incidences of CH in which care was sought Source: Bradley et al. 2017. SERVI C E DE LIVE RY 31 private providers are less likely to provide vaccination As mentioned in Section 3.2, the DRC’s government estab- services than are public providers (63 percent versus lished the CNMN in 2015. It includes an interdepartmental 83 percent), private facilities are slightly more likely to platform and technical committee of experts. Although have key child health inputs, such as guidelines for IMNCI CNMN is not yet functional at the national level, multi­ and growth monitoring; staff trained in IMNCI in the sector nutrition committees are established in South Kivu last two years; key equipment and tools such as scales, and Kasai, and the national nutrition program’s technical thermometers, and general microscopy to examine par- platform, led by the MSP, met eight times between 2016 asites in the stool; and relevant medicines and products and 2017 despite not having a dedicated budget. This (for example, ORS, zinc tablets, vitamin A capsules, multistakeholder platform comprises members of various amoxicillin syrup/suspension, and paracetamol syrup/ nutrition and food security “clusters,” development stake- suspension) (MSP 2014a). holders, nutrition-related ministries, technical and financial partners, and UN agencies. In 2016, the MSP launched a common narrative with key 4.5 NUTRITION stakeholders that led to strong advocacy efforts in the 4.5.1 Context area of nutrition (MSP [n.d.]a). The narrative called for Chronic malnutrition affects households equally in the coordination and high-level engagement among stake- DRC, except the richest 20 percent of the population. holders via a robust institutional framework, as well as The 2013 DHS estimated that 6.3 million young children interventions focusing on the first 1,000 days of life, to be experience stunting. Infant and young child feeding prac- complemented by access to care for women and children tices remain suboptimal—only 48 percent of children and nutrition-sensitive interventions. However, financial younger than 6 months are exclusively breastfed, and commitments have not been fulfilled, HRH remains under- 52 percent of newborns are breastfed in the hour follow- funded, and most nutrition-specific interventions are supported by external partners and donors. ing delivery (DHS 2013–14). Although up to 79 percent of children receive timely complementary foods, only around 8 percent benefit from complementary feeding that meets 4.5.3  Service delivery dynamics in nutrition criteria for a minimum acceptable diet. Women and chil- In 2015, the World Bank published a policy brief com- dren also have micronutrient deficiencies, with 47 per- paring the cost-effectiveness of implementing and scal- cent of children younger than five years and 38 percent ing up key nutrition interventions in the DRC. The goal of women of child-bearing age experiencing anemia. The was to help the government prioritize by identifying the childhood stunting rate is 43 percent (DHS 2013–14). most cost-effective packages and leverage additional resources from domestic budgets and development 4.5.2  Strategic collaboration and advocacy partners. Ten interventions were identified: community nutrition programs for growth promotion, Vitamin A The DRC joined the Scaling Up Nutrition Movement supplementation, therapeutic zinc supplement with in 2013 and worked with key stakeholders to draft the ORS, micronutrient powders, deworming pills, iron and National Multi-sectoral Nutrition Policy, along with its folic acid supplementation for pregnant women, iron for- costed operational plan (SUN 2017). The National Nutri- tification of staple foods, salt iodization, public provision tion Program (Programme National de Nutrition) develops of complementary food for the prevention of moderate protocols and guidelines, including the national proto- acute malnutrition, and community-based management col for management of acute malnutrition, guidelines of severe acute malnutrition in children (Shekar et al. on the nutrition community approach, and guidelines 2015). Stakeholder interviews and visits to private clin- of growth monitoring through preschool consultations ics revealed limited services and products available for in health facilities. The National Multi-sectoral Nutrition children with malnutrition. These visits found no nutrition- Plan 2017–2021 (Plan Stratégique National Multisectoriel related commodities in private clinics, pharmacies, or de Nutrition, 2017–2021) is a response to the need for a drug shops. Therapeutic products are typically offered multisectoral approach. Priority is given to interventions for free as part of humanitarian interventions, making it a targeting the first 1,000 days of a child’s life. less-profitable market for private providers. 32 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Many seeking care and treatment use the private sector, Ready to use therapeutic foods Box 16.  with 47 percent of children with fever being taken to pri- in the DRC vate providers (DHS 2013–14). The private sector accounts for over 80 percent of the sales of antimalarial agents To date, there have been no successful local production in Kinshasa and over 70 percent in Katanga (ACTWatch initiatives for therapeutic foods. Nutriset, the French cre- 2017). Most private sector outlets with antimalarial agents ator and supplier of Plumpy’Nut®, was granted a license are drug stores. Private for-profit health facilities and for local production in the DRC. The PlumpyField network pharmacies also stock antimalarials. Among outlets with tried to support local production twice, first by providing at least one antimalarial in stock, over 80 percent of pri- assistance to the food company Jongea in Lubumbashi, vate sector outlets in Kinshasa and 50 percent in Katanga and second by creating Amwili, a company specializing stocked nonquality-assured artemisinin-based combina- in the production of specific nutritional products for tion therapy (ACT), whereas approximately 20 percent humanitarian agencies, such as the UN, Doctors with- in Kinshasa and 50 percent in Katanga stocked quality- out Borders, and World Vision. Amwili’s factory in the DRC closed in 2012. Amwili’s managing director, Nataly assured ACT (ACTWatch 2017). Quality control in the K. Besnier, explained that despite their efforts and the private sector is discussed in greater detail in the Access goodwill of the Congolese state, the company could to Essential Medicines section. not continue to operate because the economic envi- Multiple projects aim to improve the quality of malaria ronment and logistical costs related to production and services in the private sector. The Global Fund and the distribution were prohibitive. Currently UNICEF provides U.K. Department for International Development are most of the ready-to-use therapeutic foods in the DRC, cofinancing a pilot project in Kinshasa to introduce sub- whereas the World Food Program provides supplemen- sidized ACT in the private sector (PMI 2017). The Defeat tary food. Rather than go through FEDECAME, these resources are distributed directly at the provincial level Malaria project is working to improve malaria treatment, (Programme National de Nutrition [PRONANUT] or DPS), as well as the availability of quality rapid diagnostic and in some cases directly to health zones. test kits and antimalarial drugs at an affordable price in the private sector by subsidizing import inputs. In Sources: UNICEF 2017; Nutriset n.d. 2016, the project helped import 921,360 green leaf ACTs, trained 1,771 providers, and supported 4,025 private organizations to distribute green leaf ACTs and distrib- 4.6  OTHER HEALTH AREAS ute 498,075 rapid diagnostic test kits (MSP 2017k). 4.6.1 Malaria Malaria is among the leading causes of morbidity and 4.6.2 Sexually transmitted infections mortality in the DRC, accounting for 39 percent of out­ and HIV/AIDS patient visits and 39 percent of deaths in 2014 (PMI 2017). The Plan Stratégique National de Lutte Contre le VIH Malaria is also the principal cause of mortality among et le Sida 2014–2017 highlights the need to engage children under five. Diagnostic and treatment services the private sector about HIV/AIDS and other sexually are available in almost all facilities, and the public and transmitted infections, including planning for sector- private sectors have similar operational scores for diag- specific plans in coordination with public and private nostic and treatment services (54 percent and 53 percent, sector stakeholders. respectively) (MSPa 2014). One of the goals of the Pro- gramme National de Lutte contre le Paludisme (PNLP) HIV testing and treatment are available in 72 percent of is to improve collaboration with the private sector. The private facilities. Operational capacity for HIV counseling PNLP’s Strategic Plan 2016–20 highlights the importance and testing, as well as treatment and support, is high in of engaging the private sector in planning, with represen- private facilities (84 percent and 74 percent, respectively) tatives from the private sector included in the malaria (MSPa 2014). technical working group, and in implementing activities, HIV prevalence among registered tuberculosis (TB) such as for the sale of full-cost or subsidized insecticide- patients in the DRC is over 11 times the prevalence in treated mosquito nets and malaria treatment (PMI 2017). the general population, at approximately 12 percent SERVI C E DE LIVE RY 33 (WHO 2016), making TB an extremely important entry point for finding new HIV patients. The Southern Africa TB in Box 17.  the Mining Sector Initiative 4.6.3 Tuberculosis The Southern Africa TB in the Mining Sector Initiative, led TB incidence (including TB/HIV coinfection) is high in by the World Bank, has facilitated collaboration among the DRC, at 324 per 100,000 persons. Unfortunately, the governments, civil society, development, and private sec- number of people developing TB has not decreased in tor partners working to combat TB in the mining sector in the past few years (Figure 24). the Southern Africa region. This initiative has successfully Despite how widespread TB is, only 30 percent of health reached multiple milestones, including the development facilities provide TB services. These are offered more of a regional harmonized framework for the management of TB supported by the rollout of training modules for widely in the public (38 percent) than in the private service providers and health workers or the geospatial sector (17 percent) (MSP 2014a). Only 51 percent of peo- mapping of all mine workers, former mine workers, their ple with TB were reached in 2016 (Stop TB 2017). Other families, and health services in South Africa. countries have developed multisector initiatives, in col- Source: World Bank 2018. laboration with mining companies, to combat TB that the DRC could learn from (Box 17). 4.7  SERVICE DEMAND cant barriers to service use. Over one-third of the popu- lation chooses not to use health services because of cost Demand for health services is limited by several factors. (Figure 25). Entrenched social and cultural norms inhibit the use of health services in the DRC—for example, misconceptions Examining demand for health services, including fac- about FP and the desire for large families prevent FP tors that drive demand, can inform social and behavior uptake. Mobilization activities are often implemented change (SBC) campaigns that aim to increase the use independently by stakeholders with limited coordination of priority health products and services. DHSs provide a among donors (for example, child health immunization great deal of information specific to demand for family campaigns) (see Box 18). For some health areas, such planning. Although there may be some differences across as nutrition, donor funding prioritizes supply-side inter- health areas, this information can highlight populations ventions, such as supplements, while efforts to increase that could potentially access health services through the demand targeting head-of-household decision making private sector and interventions that could facilitate this are limited. Willingness and ability to pay also are signifi­ access. For example, the assessment team’s analysis of Figure 24.  Number of people developing TB, on treatment, and successfully treated, 2010–16 300,000 250,000 200,000 People Developing TB 150,000 On Treatment Sucessfully Treated 100,000 50,000 - 2010 2011 2012 2013 2014 2015 2016 Source: Stop TB 2017. 34 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Main reasons for nonuse of health care Figure 25.  Changing behaviors Box 18.  in the DRC, 2013 through SBC campaigns Social and behavior change (SBC) campaigns can con­ 1% tribute to changes in both knowledge levels and behav- Cost 1% 3% 12% iors in the population, but they require a certain level of Self-medication coordination and investment. An RCT study conducted 35% Non-Necessity by DMI in Burkina Faso found that partners need to Distance 17% broadcast for around 10 weeks (10 times per day, every Time day, spread across a larger number of weeks) to change Family Refusal a particular behavior by around 9%. 31% Others Source: DMI 2016. Source: Barroy et al. 2014. the most recent DHS data reveals that there are close to Although available data limits this type of analysis to FP 15 million women in the DRC who either want to delay or for now, donors and the government of DRC could support limit their pregnancies but are not using a modern con- similar research efforts to better understand why non- traceptive method. Among women who do not currently users of child health and HIV, malaria, and other health use a modern FP method but intend to, cost and lack of products are not accessing care. This information can access are cited as the main barriers (Figure 26). inform better-targeted interventions to build demand. It Figure 26.  Percentage of nonusers of FP by type reporting reason for nonuse 100% 80% 74% 80% 70% 66% Percent of non-FP users 64% 66% 56% 59% 58% 55% 60% 53% 50% 50% 45% 44% 47% 41% 42% 36% 34% 34% 40% 30% 26% 20% 20% 0% g x ic ex d s ed ce ed on h s t s se in uc rie he ec ce ts ur os os iti ed m ar ng rr eff so ac ib pp pp en fe o m o oh vi en no to ro qu of to st e ha t sid pr No am ea re ne ck en s s t st ow us Br f No of La rt d In um Co on io pa Kn ar lig sp rt d/ Fe Re pa Re an st sb Po Hu Non-user - intends to use later Does not intend to use Source: DHS 2013–14. SERVI C E DE LIVE RY 35 can also inform interventions to make private providers provide key data to inform decision making, as highlighted more capable of fulfilling existing unmet demand, includ- below in the Health Information Systems section. ing clinical trainings to expand private provider service offerings, supply chain interventions to improve private Strengthen private provider access to clinical trainings, provider and retail outlet access to pharmaceutical prod- especially for FP ucts, and health financing strategies to address high costs Finding: Although there is a general perception of better at private facilities. quality services in the private sector, providers often offer a limited range of services because of lack of clinical skills. 4.8 RECOMMENDATIONS Donor-sponsored programs also tend to focus on public This section provides recommendations for private sector sector, FBO, and NGO providers, omitting the private service delivery, particularly in FP and MCH. for-profit sector. As a result, private providers often do not receive regular updates about FP and other services. Collect additional information on service delivery Recommendation: Donors and governments should con- in the private sector sider new strategies for reaching private providers with new and refresher trainings for FP and other services. Finding: There is limited information available about the These efforts should leverage existing efforts by networks demand for products and services in the private sector, such as ABEF or PSI that currently deliver trainings on FP the number of private providers, the role the private counseling and service provision to their members and sector plays in the provision of products and services, partner providers. Expanding these training programs as well as the quality of products and services they to cover new health areas (for example, TB or HIV) and provide. reach more providers can help increase the availability Recommendation: Stakeholders should integrate ques- of a greater range of services in the private sector. By tions regarding the private sector in upcoming studies, working through an existing network or provider associ- such as WHO’s next SARA, and invest in complementary ation, donors and governments can also build more links studies to better understand the role private providers among these groups and larger numbers of independent play in service delivery. Better integrating the private private providers, thereby helping to address some of the sector in the national health information systems will also fragmentation that currently characterizes the private health sector. Invest in programs that address cost barriers to FP services in the private sector Finding: Cost is a barrier to the use of family plan- ning services—especially long-acting methods such as implants—in the private for-profit sector. Recommendation: Although efforts to use vouchers have been limited in the DRC (mainly focused on humanitarian efforts and child health), donors and the DRC govern- ment may want to consider supporting such an effort. In other countries in the region, these programs have helped reduce financial barriers and increase access to priority health services (Box 19). Leverage an integrated four-pronged approach to improve child health case management Madame Lusandu Chantale, FP Specialist at the Centre Hospitalier Findings: The DRC’s IMNCI strategy objectives include de Reference de Libikisi of the Église du Christ au Congo, Kinshasa building capacity, improving availability of IMNCI drugs, 36 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Four-pronged approach to Figure 27.  Using vouchers to increase use of Box 19.  improve ORS and zinc use priority health services in Uganda To address Uganda’s high maternal mortality rate, USAID Enabling policy Sustainable quality invested in a maternal health voucher program in four environment supply districts from 2012 to 2014 as part of the Saving Mothers, Increase ORS Giving Life Initiative. As implemented by Marie Stopes and zinc use Uganda, women could purchase a low-cost voucher from Provider knowledge Caregiver knowledge a community-based distributor that covered a suite of and practice and practice maternal health-related services, including antenatal visits, delivery, and testing and care for pregnancy- related complications. These vouchers were redeemable at participating Marie Stopes clinics that had received child health products in the public and private sectors; proper clinical training. Once vouchers were redeemed, 3) generating demand for products and teaching care- providers submitted claims for payments to Marie Stopes givers when and where to seek treatment and how to Uganda. These payments were higher than what the correctly use products; and 4) improving knowledge women originally paid for the voucher, allowing low- and skills of providers in both the private and public income clients to access high-quality care in the private sectors to promote and deliver appropriate treatment. sector and private providers to recoup the costs of their service provision. Over the course of this two-year pro- They should also build the capacity of drug shop counter gram, over 36,000 women purchased a voucher. Ninety- agents to prevent and treat childhood illnesses, using four percent redeemed them for antenatal care and 74% training and supportive supervision to improve prescrip- for delivery. tion practices. Source: SHOPS Project 2015. Increase private sector engagement in nutrition programs Finding: Private sector engagement in nutrition programs remains relatively limited. scaling up family- and community-based IMNCI practices, Recommendation: Specific opportunities to engage the and improving coordination among all stakeholders. This private sector include: assessment revealed political will for using the private sector to improve child health outcomes and reflected yy Assessing the feasibility of working with local private a consistent supply of zinc and ORS in drug shops in companies to package nutritious food (for example, Lubumbashi. fortified oil for cooking) in small quantities that can be sold at a more accessible price; Recommendation: To take advantage of this political will, donors and the DRC government should support an yy Promoting local food fortification (that is, wheat integrated multichannel SBC campaign focusing on child flour, salt iodization); health and using lessons from past campaigns in the DRC yy Engaging the private sector to transport therapeutic to inform design. Through expanded use of the private products to difficult-to-access areas; and sector in other countries, donor programs have addressed preventable child deaths in several field programs using yy Organizing a private sector network to contribute a four-pronged approach (Figure 27): 1) securing a con- to the national nutrition plan and ensure that pri- ducive policy and regulatory environment for treatment; vate sector stakeholders are aware and engaged in 2) ensuring wide availability of high-quality, affordable nutrition efforts. SERVI C E DE LIVE RY 37 5.  Access to Essential Medicines 5.1  OVERVIEW OF THE SUPPLY CHAIN The current state of the supply chain reflects the size of the DRC and its poor infrastructure. The supply chain is large, complex, largely unregulated, and characterized by fragmentation and duplication. In 2009, there were 99 distribution channels for the public and nonprofit sector, with 85 percent of partners using their own procurement agencies, warehouses, and distribution systems, causing waste and duplication (Ntembwa and van Lerberghe 2015). Implementation of the National Supply Chain Sys- tem in 2009 had not had a significant impact on this situation by 2014 (SIAPS et al. 2014). The private sector plays a significant role in procuring and distributing medicines and supplies to private phar- macies, drug shops, clinics and hospitals but is even more fragmented than the public-sector distribution sys- reference, in other francophone countries (Côte d’Ivoire tem. The government can only estimate the number of and Senegal), there are only four to five authorized whole- private importers, wholesalers and drug shops because salers (grossistes répartiteurs) serving the entire country, registration and regulation are ineffective (Table 5). with over 1,000 verified authorized pharmacies. This econ- The government’s need to estimate unauthorized whole- omy of scale allows the wholesalers to invest in logistics salers speaks to the lack of regulation. As a point of for better storage and delivery directly to pharmacies at Pharmaceutical manufacturers, authorized private wholesalers, wholesalers, Table 5.  and authorized pharmacies in the DRC,* 2017 Manufacturing Authorized and Unauthorized Province Authorized Pharmacies Laboratories Wholesalers Total in the DRC 30 171 109 Kinshasa 21 90 90 Haut-Katanga 3 29 11 North Kivu 1 3 0 South Kivu 2 12 1 Kasai-Oriental 1 1 1 Kongo Central 2 8 1 Orientale 0 0 4 *Based on former provinces. Sources: MSP 2017b, 2017c, 2017d, 2017e, 2017f. 38 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O short notice. The DRC represents an extreme case where developed their own systems for critical supplies for emer- diseconomies of scale result in greater challenges to gency and priority programs. The FEDECAME model is a regulators and lower quality. public–private mix—both the CDRs and FEDECAME are Authorized pharmacies are outnumbered by unauthorized nongovernmental, nonprofit associations, and the national pharmaceutical retail outlets. A WHO study from 2015 government gives them a mandate to supply public-sector estimated that there were approximately 4,000  un­ - facilities. The MSP aims to have at least one CDR per prov- authorized facilities dispensing drugs, which is much ince. The government and its partners have helped estab- greater than the MSP numbers in Table 5. Another study lish most CDRs by providing office and storage space, found over 5,000 drug shops in Kinshasa with neither technical assistance and training, and capital investment a permit nor a qualified pharmacist (Office Fédéral des for vehicles and equipment. Many of the CDRs were con- Migrations [ODM] 2014, 7sur7.cd 2015). The presence verted from procurement units established by FBOs or of unauthorized pharmacies and wholesalers makes it international NGOs. For example, the Association Régio- difficult to accurately estimate the size and scope of nale d’Approvisionnement en Médicaments Essentiels the private sector supply chain. Although stakeholders (ASRAMES) in Goma was initially established by Doctors condemn the dominance of unregulated drug shops, without Borders Holland and eventually converted into a they also acknowledge the DRC’s dependence on them CDR and integrated into the FEDECAME system. for access to medicines and the inadequate number of Although FEDECAME’s primary mandate is to supply pub- trained pharmacists to replace them. lic facilities, the government envisions that FEDECAME will integrate the procurement and logistics functions of 5.2  PUBLIC/NGO SUPPLY CHAIN international and faith-based NGOs, thereby reducing fragmentation and duplication. Ideally, this consolidation Since the collapse of the health system in the 1990s, the would help the CDRs and FEDECAME achieve a scale government has slowly rebuilt a supply chain that inte- that increases their prospects for financial sustainability. grates CDRs with FEDECAME, the central procurement However, the current system does not cover the entire unit. However, regional and vertical aid programs have country, and parallel programs persist in the absence of a robust national supply chain. There are currently 19 authorized CDRs across the DRC, many of which are in heavily populated areas, such as Lubumbashi, Mbuji- Mayi, Kinshasa, Matadi, and Goma (MSP 2017b). These are at different levels of functionality, financial stability, and capacity. Although FEDECAME is supposed to pool procurement, several CDRs procure through other chan- nels that they can access more easily, demonstrating the challenge of establishing a single procurement unit for the entire country. In addition to logistical limitations, the FEDECAME and CDRs must also balance serving the public sector while operating as financially sustainable, independent non- profit entities. Ideally, CDRs recover their operational costs on the sale of products to health zones, but public- sector facilities are not always well managed and may not pay their bills. Moreover, public-sector facilities do not always purchase their products through FEDECAME. The government provides some advance funding to FEDECAME to ensure sufficient funds for procurements, ASMARES Warehouse, Goma but ultimately the system still depends on cost recovery ACCESS TO ESSENTI AL M E DIC INE S 39 from patients. This inhibits the ability of the CDRs to FEDECAME also struggles with accurate procurement achieve scale, stabilize, or become solvent. For example, forecasting because many programs operate inde- CAMESKIN, the CDR in Kinshasa province, incurred a loss pendently, importing products for HIV, malaria, and FP of $561,037 in 2016 and carries $124,180 in debts on its without consultation. If a CDR procures specific prod- balance sheet (CAMESKIN 2017). ucts without knowing that an international partner is CDRs earn no margin on the sale of products when they planning to bring in large quantities for free, the CDR are provided for free by donors. Although only a few risks expired stocks and financial loss. CDRs are espe- international programs have integrated their procure- cially cautious in procuring medicines for priority pro- ment into the FEDECAME system, many have supported grams, thus perpetuating the need for donor programs. CDRs by contracting them for the storage, tracking, and One CDR, for example, has stopped procuring anti­ distribution of free products. Each contract is negoti- malarial drugs because the needs of the population are ated separately, but there are some common practices. covered by donor and international NGO procurements. Storage is never billed on the basis of weight, volume, Some international organizations interviewed as part of or surface area occupied because such criteria are sub- the assessment continue to procure quality medicines on ject to dispute and difficult to monitor. Instead, CDRs bill the global market because they are working with larger 6–8 percent based on the product value as it is docu- volumes and can obtain better prices. FEDECAME also mented on official importation documents. Some pro- requires much longer lead times (10 months). At least grams also provide performance incentives to increase one organization raised concern about FEDECAME’s above the base percentage if CDRs meet standards for quality systems. Given these factors, it seems unlikely delivery times with minimal loss or damage. This income that international organizations will shift their medicine is an important source of additional revenue. For example, procurement to FEDECAME in the near future. one CDR earned $84,392 from the sale of medicines in 2016, while in the same time period they earned $1,027,097 in contracted storage services and another $130,048 in 5.3  COMMERCIAL SECTOR SUPPLY CHAIN delivery services. 5.3.1  Local manufacturing Only 10 percent of commercial sector pharmaceutical products in the DRC are manufactured locally (Office Fédéral des Migrations 2014), and most production units are in Kinshasa (MSP 2011). Local pharmaceutical manufacturing is highly dependent on imported inputs and packaging equipment, and multiple import taxes increase costs and lower price competitiveness, which does not encourage local production (MSP 2011). Local manufacturers face other challenges, such as irregular and expensive utilities, high transportation costs, and corruption. Furthermore, the tax rate is the same on manufacturing inputs as finished products (see Box 20). Most local pharmaceutical manufacturers have not achieved Good Manufacturing Practices certification (MSP 2011), and as a result, FEDECAME procures little from them. For example, FEDECAME received submis- sions only from Pharmakina, which is Good Manufacturing Practices certified, in response to a recent request for quotations. Moreover, consumers perceive locally manu- factured products as poor quality, so pharmacists are Pharmacie Hekima Saint Etienne, Goma reluctant to stock them. 40 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Box 20.  Customs regulations and import duties and taxes The Directorate of Customs and Excise (Direction Générale des Douanes et Accises) assesses and collects tariffs and duties for imports based on established rates under the DRC’s tariff schedule. Import duties and taxes are the same for specialty and generic pharmaceutical products. The rates are the same for finished products, as well as manufacturing inputs. Importers pay a number of taxes and duties, including embarkation and disembarkation fees, import licenses, airport taxes, industry promotion funds, and others (MSP 2011, export.gov 2017a). As with other pharmaceutical products, the importation of contraceptives and condoms into the DRC is subject to payment of customs duties, taxes, and other fees, including an administrative fee of 5 percent (UNFPA 2017a). This taxation results in an increase in the price of products, as demonstrated by the approximately 60 percent markup for contraceptives (UNFPA 2017a). Donor agencies such as UNFPA, USAID, Department for International Development, and some NGOs are exempted from cus- toms duties but are not exempt from the 5 percent administrative fee. 5.3.2  Importers and wholesalers and South Africa, entering the country via Tanzania and Zambia. In Mbuji-Mayi, drugs were received primarily The 2016–20 National Health Development Plan esti- from the southern route via Lubumbashi. mates that in 2015, the pharmaceutical market—including both public and private sectors—totaled US$457.4 million (MSP 2016). Many drugs are imported by international 5.3.3  Pharmacies and drug shops aid organizations implementing emergency assistance The retail sector is dominated by unregistered drug shops programs, and the value of their imports may not be cap- calling themselves pharmacies—estimates vary from tured in this analysis. 8,000 to 10,000 compared to 109 registered pharmacies. As noted, it is difficult to quantify the number of Drug shops are typically operated by an owner or staff wholesalers/importers and retail outlets because of inadequate regulation and registration. The MSP esti- mates 171 wholesalers/importers are active in the DRC, but few have national presence or capacity, and most focus on selected markets in large towns or cities. The assessment team surveyed 34 pharmacies and drug shops in six cities, and no wholesaler was named as a principal source of supply in all. Few wholesalers offer credit to clients or deliver products to pharmacies or drug shops; most operate depots, selling to clients who come and purchase on a cash-and-carry basis. There is no system for verifying that purchasers are qualified phar- macists or even owners of pharmacies. In addition, many private importers sell medications of questionable qual- ity (Office Fédéral des Migrations, 2014). Based on data collected by the assessment team from retail drug shops, imports seem to be sourced from different parts of the world depending on location in the DRC. In Kinshasa, for example, more imports were from Europe and the United States, whereas in the east, imports came from Tanzania and Rwanda, with suppliers bringing drugs through Dar es Salaam. In Lubumbashi, medicines were from Asia Drug shop in Matete, Kinshasa ACCESS TO ESSENTI AL M E DIC INE S 41 Figure 28.  Outlets stocking modern contraceptive methods 1% 3% 1% Drug Shop 6% 2% Public Health 11% Facility 3% Community 9% Health Workers 25% Nonprofit Private 59% Facility For-Profit Private 79% Facility Pharmacy N = 350 for Katanga and N = 433 for Kinshasa. Source: PSI and FPwatch 2015; Bradley et al. 2017; PMI 2017. member without any training in pharmacy; most dispense the range of prices for quality-assured ACT in Katanga drugs without a prescription, encouraging the common was $1.10–$2.19; the range for similar or identical quality- practice of self-medication. Unregulated drug outlets assured ACTs in Kinshasa was $4.93–$8.77. compete with registered pharmacies (operated by fully A major influence on price inflation is the lack of pur- qualified pharmacists), making qualified pharmacists less chasing power of clients and the lack of effective health likely to open and operate quality pharmacies. The Order insurance programs to cover the cost of medicines. A of Pharmacists indicated that this means pharmacists number of key informants cited difficulties among their are seeking employment elsewhere, including other sec- target groups in affording medicines and questioned the tors and countries. Most drug shops receive little or no wisdom of the public sector’s adoption of a cost recov- credit from wholesalers, and as a result, stockouts occur ery system. This is especially true in the eastern part of frequently because of the shops’ lack of liquidity rather the country, where insecurity and unemployment are than unavailability of medicines. Despite these issues, drug shops are essential for ensuring the availability of medicines in the DRC, and closing them all would not be desirable or feasible. Figure 28 shows that drug shops represent between 59 percent and 79 percent of contra- ceptive selling outlets. 5.4  ACCESSIBILITY AND PRICING OF DRUGS Drug prices are regulated by the Ministry of the National Economy (Ministère de l’Économie Nationale), which sets the profit margin at 20 percent for wholesalers and 33 percent for pharmacies. Although prices for generic drugs are almost the same in the public and private sec- tors, prices for branded drugs are higher in the private sector (MSP 2011). It is unclear whether pricing regula- tions are followed because there is no monitoring, and few medicines have prices on them. Lack of enforcement, the large number of drug brands, and market regionaliza- tion contribute to price variations. For example, in 2015, 42 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Informal survey results of 21 pharmacies and drug shops for child health products Box 21.  in Lubumbashi The analysis of the data collected from 21 pharmacies and drug shops found: yy Eighty percent carried ACT. Twenty-seven different brands of ACT were found in the Lubumbashi retail audit, whereas only 29 percent of those surveyed stocked rapid diagnostic tests. yy Seventy percent of outlets carried ORS, the majority of which was the low-osmolarity formulation. Twelve brands were sold at a price range of CDF 100–3,000 (US$0.06–$1.87) per sachet. yy Forty-eight percent of outlets carried zinc as a stand-alone product, the majority of which was Pedzinc, manufactured by Beta Healthcare International Ltd. in Kenya. The price range for a 10-tablet blister was CDF 50–2,500 (US$0.03–$1.56). yy Twenty-nine percent of outlets carried pediatric zinc and ORS copack. Approximately half of the copacks were OraZinc, manufactured by Maharashtra, in India. The price range for the copack was CDF 0–10,000 (US$0–$6.25). yy No commercially branded therapeutic nutrition products were found. yy At one location in front of a large private clinic in Kinshasa, locally hand-packaged bags of a maize-like porridge were found. Ingredients included soy, corn, caterpillars, and kikalasa (a grain/vegetable product), prepared by mixing the ingredients, adding water with a spoonful of olive oil and some sugar and milk, if available, after cooking. The packet is prescribed to children who come to the clinic with signs of malnutrition (low weight, stationary weight, anorexia) and is sold for CDF 1,500 (US$1). major challenges, especially in unstable or refugee situa- tration, and increasing the percentage of items listed in the tions. According to MSF Holland, fewer than one-seventh national essential medicine list with registered products of people in their project areas can afford to pay for ser- (Table 6). vices or medicines (MSF 2017). However, there are still issues around registration costs. In Sensitivity to high prices may also be a factor in driving most countries, the entity charged with registering drugs demand for cheap but substandard medicines. An informal has some autonomy from the MSP, and the fees it charges survey of drug shop outlets as part of this assessment for each application are used to defray the costs of showed that for some common medicines (amoxicillin assessing the application, including the costs of inspect- and ciprofloxacin), there were as many as 20 different ing manufacturing facilities and verifying documentation brands available with a large range in prices (see Box 22). submitted. In the DRC, fees are charged only for drugs For low-income consumers, pressure will be toward that are actually registered, and the fees are paid directly choosing the cheapest brands without regard to whether to the treasury, so they do not support the increased bur- or not they are quality assured. Prescribing habits also den of evaluating applications (MSP 2017j). In addition, contribute to cost. A prescription in the DRC includes on average seven different medicines, some of which perform Medicine registration efficiency Table 6.  the same function, but consumers lack the knowledge and effectiveness to know the difference. This tends to increase out-of- Current pocket expenditures on health, particularly among the Indicator Baseline (2016) poor (Ntembwa and van Lerberghe 2015). Medicines registered with the DPM 400 (2011) 4,600 Days to process registration 84 (2013) 58 5.5  REGISTRATION AND PHARMACOVIGILANCE Percentage of items listed in 44 (2011) 64 The MSP’s reforms have improved the registration sys- National Essential Medicines List tem by increasing the number of medicines registered, with registered products decreasing the number of days needed to process regis- Source: SIAPS 2014 ACCESS TO ESSENTI AL M E DIC INE S 43 the DPM has not yet established clear criteria for refus- needed to see how the network can be more responsive ing drug applications based on public health benefit. The to international NGO needs. DPM director noted that each pharmaceutical company Recommendation: Through existing programs of the can register its own brand of common molecules and World Bank and other partners, provide technical support market those brands to retail outlets regardless of how to FEDECAME beyond procurement, storage, and logis- many similar products are on the market. The DPM is still tical issues to also include cost controls, marketing, and responsible for ensuring that all imports meet quality risk management around bad debt, overstocks, and com- standards, so this regulatory gap increases the burden of petition (World Bank 2017b). Technical assistance should monitoring drugs, making it harder to establish a compre- also target the governance of the FEDECAME system. hensive database of all drugs registered in the country. An estimated 40–45 percent of medicines sold in the Support CDRs to better manage their bad debt risk DRC are counterfeit (Office Fédéral des Migrations, 2014). Finding: CDRs urgently need new strategies or systems Poor-quality medicines circulate in part because the for managing their bad debt risk from public-sector facil- MSP lacks the resources to implement a strong quality ities and health zones. The current system of the public assurance program (MSP 2011). The MSP does not have a sector providing a line of credit from the national budget national drug control laboratory of its own but relies on is suboptimal. For the FEDECAME network to expand, the laboratories at the University of Kinshasa, the Congolese level of capitalization should be increased significantly Office of Control (Office Congolais de Contrôle, OCC), each year. Instead, the CDRs’ bad debts undermine needed and two private laboratories. Many of these lack ade- growth. quate equipment and cannot perform specialized tests (MSP 2011). The OCC laboratory is the only one accred- Recommendation: Technical assistance should be pro- ited to ISO 17025 standards (WHO 2015) and has primary vided to the FEDECAME network to increase their access responsibility for drug testing. With 24 labs throughout to operating capital and identify ways to minimize their the country and an additional three planned, the OCC has risk from bad debts. As an example, the central purchas- significant capacity. However, the OCC also has a huge ing unit in Senegal, rather than transferring title to medi- mandate to test drugs, food, construction equipment, cines to health zones, established their own depot in the and materials, and must test products being exported largest hospitals to sell medicines on a cash basis to con- as well as imported. The system for notification of pos- sumers and health facilities. This combines the continued sible side effects or cases of suspected substandard or availability of medicines and the needed cost recovery. counterfeit drugs is still mostly ad hoc. The DPM director acknowledges this and has plans to establish a commis- Encourage collaboration among donors, sion to improve post-marketing pharmacovigilance sys- international NGOs, and the FEDECAME system tems but currently the lacks the resources. Finding: Although Programme National d’Approvisionne- ment en Médicaments Essentiels (PNAME) would like 5.6 RECOMMENDATIONS more international organizations and large vertical pro- grams (for example, PEPFAR, Global Fund, and PMI) to Recommendations to increase private sector provision fully integrate into the FEDECAME system, this is not fea- of essential medicines include: sible at this stage. 5.6.1  Reinforce the FEDECAME System Recommendations: International organizations can sup- Continue to provide technical support port the FEDECAME network by: to the FEDECAME system yy Increasing efforts to coordinate their procurement Finding: Although the capacity of the FEDECAME net- and distribution with the FEDECAME network and work, as well as individual CDRs, is limited, strengthening PNAME, particularly to assist with forecasting of needs this system is a critical strategy for improving access to and improve CDR planning and risk reduction; and quality medicines in the public, nonprofit, and faith-based yy Continuing and/or expanding the existing practice of sectors throughout the country. In particular, efforts are contracting storage and distribution to CDRs because 44 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O it is an important source of technical support and Order of Pharmacists and others have conducted some operational financing. small-scale awareness campaigns, but consumers do not necessarily know which shop or package of medicines 5.6.2  Reform Pharmaceutical Distribution is good. A campaign is needed to help consumers iden- tify which shops have been certified and how to identify Comprehensive reform of the commercial questionable drugs. In addition, if other investments are pharmaceutical sector made for a web-based drug registration list and an easier- Finding: The private sector supply chain needs major to-use alert system, consumers could be encouraged to reforms. Stakeholders recommended a new scope for check suspect drugs against the national registry and drug outlets based on the Tanzania Accredited Drug Dis- report unusual side effects or ineffective medicines into pensary Outlet model. This requires drug outlets to sell the pharmacovigilance system. only to registered pharmacies or accredited drug out- Recommendations: lets; track the lots of all medicines sold; deliver directly to approved points of sale; provide 30 days’ credit on sales yy Define a new scope of practice for drug shops to of essential medicines; and meet all global standards for sell selected essential medicines (not the full range space, storage conditions, and handling of medicines. of medicines available from a registered pharmacy) This would require a new training program, with involve- and develop a curriculum and training program for ment of the Order of Pharmacists and medical schools, all drug outlet operators. Put all drug shops on notice to ensure adequate supply of qualified staff and increase that they have one year to go through the retrain- production of pharmacist candidates. However, multiple ing program and reregister. After the initial year, they would be subject to fines or closure. problems must be addressed. For example, DPM inspec- tors currently operate independently and can only make yy Raise drug wholesaler standards and put existing warnings or render technical recommendations—only law wholesalers on notice to reach the standards or be officers have the authority to close a business. Long-term shut down within a year or less. The DPM could iden- enforcement is critical to sustaining progress. In addition, tify key wholesalers using import data from the Min- the chances of successfully reforming the private pharma­ istries of Commerce and Finance as well as data from ceutical sector are much lower if consumers still buy the the DPM’s planned mapping of private pharmaceutical lowest-priced medicine with no thought to quality. The supply chain stakeholders. During the probationary year, the DPM and technical partners can provide technical assistance but should actively encourage consolidation and a reduction to a smaller number of wholesalers with greater capital investment and more logistical capacity that are easier to inspect and monitor. yy Invest in building the capacity of the Inspection Générale de la Santé to supervise and enforce drug regulations, including undertaking regular inspections and sanctioning of pharmaceutical premises. Create a special unit that includes duly authorized officers of the law, mandated by the Minister of Justice, to work closely with them to close down unregistered or non- compliant drug shops and wholesalers. Put in place the administrative procedures for this unit, recruit and train new inspectors, and define standard operating procedures. yy Design and implement a public awareness campaign Madame Elodie, Pharmacie Kibaphar, Lubumbashi to sensitize people about the dangers of buying ACCESS TO ESSENTI AL M E DIC INE S 45 Box 22.  Sproxil and mPedigree: pharmacovigilance through digital consumer engagement Sproxil and mPedigree use mobile technology to combat drug counterfeiting, drive revenue, and engage consumers at the point of sale through brand assurance, fraud protection, and loyalty rewards. Sproxil and mPedigree partner with pharma- ceutical companies to label products with codes that can be authenticated by text message at all points on the global supply chain, including by the consumer when purchasing a product. The codes can also be used as a loyalty program so that cus- tomers who verify their products can win prizes or rewards. With products in Mali, Nigeria, Tanzania, and Pakistan, Sproxil has demonstrated its ability to function in some of the most challenging settings. mPedigree’s text-based mobile product authentication service system has already appeared on 6.5 million packs of medicine and has been adopted as the national standard in three different countries. Sproxil and mPedigree could potentially be used as tools to develop the market for the local pharmaceutical industry. Source: Sproxil 2017; Cadwalladr 2012. unregistered medicines and the importance of using tunities for any pharmacist to gather needed resources to registered drug shops. Partner with drug manu- open an additional shop in low-income neighborhoods, facturers to design a smartphone application that which is often where the need for improved access to consumers could use to check the lot number of a quality medicines is greatest. package they are considering buying against the Recommendation: Encourage the creation of networks national registry of medicines (Box 22). for pharmacist owners by giving them access to a guar- yy Support the DPM to enforce new legislation by ensur- antee fund for loans designated for the expansion of ing all shops adhere to the new scope of practice and drug outlet networks. As a condition for receiving access that wholesalers are adhering to the new regulations. to credit and additional technical assistance, the network Focus the rollout of increased vigilance on major cities owners would agree to respect national siting require- first and gradually expand throughout the country. ments and open some outlets in underserved areas. This would prevent concentration of pharmacies and drug yy Advocate for government and its financial partners outlets in wealthier urban areas and allow the network to to make long-term budget allocations to launch and cross-subsidize outlets in lower-income neighborhoods. maintain monitoring. The planned mapping of private supply chain actors could inform this activity by identifying current coverage Encourage the creation of pharmacy of pharmacies and drug shops. and drug shop networks Finding: Congolese law permits ownership of a pharmacy 5.6.3  Encourage local manufacturing and to nonpharmacists, provided the owner employs a phar- support the development of the supply chain macist to oversee operations and follow professional stan- dards. This regulation creates an opportunity for owners Evaluate the feasibility of revising the customs and to develop networks of pharmacies. This could allow net- taxation regime to incentivize local manufacturing works to achieve economies of scale and procure drugs Finding: The customs and taxation regime is not differen- in larger quantities, brand franchises, manage stocks tiated for the import of primary inputs and final products. better, and improve access. It could also facilitate regula- This increases costs for local manufacturers, who have to tion because authorities will be able to deal with a single import primary inputs, making their products more expen- legal entity and cover all of the drug shops owned by that sive and less competitive. To reduce dependence on foreign entity. If corporate entities own drug shop networks, they imports and promote economic growth, the government will be more likely to mobilize capital through investors and donors should do more to encourage local production and bank loans. Current practice, though, continues to of high-quality medicines. This can be done through policy emphasize one pharmacy per pharmacist, limiting oppor- reform, technical support, and access to financing. 46 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Recommendation: Assess the feasibility of revising the yy Conduct a market study to identify which medicines customs and taxation regime to incentivize local man- international organizations are most likely to pro- ufacturing by taxing imported drugs ready for sale at cure locally and where local manufacturers have the a higher rate than that for pharmaceutical ingredients greatest comparative advantages. imported for manufacturing and production. yy Identify opportunities for international manufacturers to invest in opening a local manufacturing plant in Invest in the logistical capacity of the supply chain the DRC. Other countries have experienced success developing local manufacturing through foreign direct Finding: Both existing CDRs and improved private investment (FDI). In 2017, the Bangladesh company wholesalers need to expand their capacity to deliver and Square Pharmaceuticals invested $75 million in Kenya handle medicines according to pharmaceutical norms. to open a local manufacturing factory with the World This can be done in-house or contracted out to private Bank Group’s technical assistance (BTOR 2017). firms that specialize in this service. Some existing trans- portation companies may wish to add this service as a specialization to increase their scale. Under all such sce- Establish a searchable web-based database narios, new investment in developing or expanding this of registered drugs capacity is needed to improve the logistical capacity for Finding: Stakeholders expressed concerns about the CDRs and the private wholesalers and increase access to quality of pharmaceuticals in the private sector without a quality-assured medicines. strong, easily accessible system to track commodities and supplies. As previously noted, 40–45 percent of drugs sold Recommendation: Conduct regional analyses of the trans- in the country are counterfeit. Increasing access to infor- port sector to identify the main service providers and their mation about which drugs are registered is an important reach, capacity, and constraints. Provide targeted capacity step in addressing this challenge. Thanks to the support building to the companies with the largest and best- of the World Bank-funded Human Development Systems managed distribution networks regarding the transport Strengthening project, the DPM has set up a website that of medicines (for example, disseminate requirements, provides a directory of registered drugs in PDF format. build cold chain capacity, and so on). Once they are ready, Recommendation: A user-friendly, more-interactive online prequalify them to work with the government and other database of registered drugs could serve as an effective stakeholders (for example, CDRs, private wholesalers, regulatory tool; for example, mPedigree, a Ghana-based international NGOs). technology company, currently has mobile and online platforms and partnerships in 10 countries across Africa Provide technical support to local and international and Asia to track and report counterfeit pharmaceuti- manufacturers with the most potential cals (see Box 22). DPM and its partners should translate Finding: Given the numerous challenges to local manu- the existing PDF lists of registered drugs available on the facturing, it is unlikely that local manufacturers will greatly DPM website into an interactive, searchable database that increase their contribution to commercial sector supply. pharmacists, drug shop operators, and consumers can However, with targeted support, the more able ones could easily access. Additional partnerships with private sector supply higher-quality essential medicines. The major bar- actors could strengthen the functionality of such a data- rier for local manufacturers is their failure to achieve qual- base. Partnerships with manufacturers could generate ity standards so they can participate in FEDECAME and additional financial support and necessary information on international organization tenders. their medicines to support multiple levels of verification to consumers. Mobile network operators could also support Recommendation: the use of a mobile application to allow pharmacists, drug yy Provide technical support through the WHO to shop owners, and consumers to verify that a medicine is manufacturers who are willing to invest in quality registered with the DPM and has been approved for sale improvement. following quality assurance testing. ACCESS TO ESSENTI AL M E DIC INE S 47 6. Financing Health financing is essential to improving access to health care services in the DRC. This section focuses on two components: 1) demand-side mechanisms, such as insurance, that can reduce finan- cial barriers to accessing care at private facilities and provide greater financial protection against catastrophic health spending, and 2) access to financing for private providers to expand operations. 6.1  HEALTH FINANCING Out-of-pocket spending is much higher at private health facilities than at public ones (Table 7). The 2017 Health Financing Strategy documents the cur- rent fragmented approach to health financing and spells Given the reliance on out-of-pocket expenditure, many out medium- and long-term visions for rationalizing mobi- Congolese face catastrophic health expenditures. A 2017 lization and use of financial resources. This includes con- study reported that 19 percent of households had incurred solidating funding from public and private sources and health expenditures that exceeded the resources available creating a pool from which to purchase health services to them in the 12 months preceding the survey (PDSS and from public and private providers (MSP 2017h). PVSBG 2017). Catastrophic expenditures on health dis­ proportionately affect the poor (Barroy et al. 2014). Health expenditure: sources, trends, 6.1.1  and implications 6.1.2  The DRC’s approach to reaching UHC Health in the DRC is underfunded. The percentage of According to the country’s PNDS, low allocation of pub- government budget allocated to health has fluctuated lic resources to health and insufficient risk-sharing and in recent years from 3.5 percent in 2011, to 7.8 percent health financing mechanisms are major challenges that in 2012, to 4.6 percent in 2013, and is well below the limit progress toward UHC. The PNDS estimates a funding 15 percent Abuja declaration threshold (WHO 2011). Budget spending also has been low—27.2 percent in 2012 and 37.6 percent in 2013 (ONRHS-RDC 2015). House- Current expenditure by source Figure 29.  holds represent the largest proportion of health expen­ of financing, 2014 diture, followed by donors (Figure 29) (PNCNS 2016), and together the two account for 82 percent of total health expenditure. Almost two-thirds of expenditure is for curative services, with an additional 30 percent spent on 4% pharmaceutical products and other nondurable medical 14% goods (PNCNS 2016). Households 42% Donors Out-of-pocket payments account for 93 percent of house- Government hold expenditure, with just 7 percent used to pay health insurance premiums (PNCNS 2016). The share of out- Companies 40% of-pocket expenditure as a percentage of total health expenditure is high compared with that of other coun- tries in the region (Figure 30). Source: PNCNS 2016. 48 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Figure 30.  Share of out-of-pocket expenditure as a percentage of total health expenditure, 2016 50% 40% Expenditures Total Health DRC 30% Liberia 20% Namibia 10% Rwanda 0% 2010 2011 2012 2013 2014 Source: Wang et al. 2016. Table 7.  Average out-of-pocket health expenditure by type of provider* Provider type Average Public Private Other** Inpatient care 47.9 95.1 60.4 59.5 Outpatient care 15.9 19.1 10.4 16.9 * In constant 2010 US$ in the DRC for the most recent health care services received. ** Other includes shops, traditional practitioners, mobile vendors, and drug peddlers, among others. Source: Wang et al. 2016. deficit of CDF 325–488 billion (US$346–US$520 million)2 yy Health mutuelles will be developed at the health for the 5-year period to provide essential health services zone level; to all. To close the funding gap, the DRC would need to yy Provincial governments will support studies on how triple existing financing, estimated at US$18–US$33 per to determine the ability of households to pay and person per year (Barroy et al. 2014). Other challenges cited how public and private stakeholders can collaborate in the PNDS include fragmentation of official development to provide health insurance; assistance, inefficiency, and weak application of financial management procedures. yy Civil servants will be required to enroll in a health insurance scheme; and To overcome these challenges and ensure affordable access to quality health care, the PNDS identifies four yy State subsidies are envisioned to pay contribu- major programs: 1) resource mobilization, 2) pooling and tions to health mutuelles on behalf of poor and streamlining the allocation of resources, 3) development vulnerable households (potentially a majority of of risk-sharing and health-financing mechanisms, and citizens). 4) improving management of financial resources in ser- Each of these approaches has implications for private vices and facilities. providers and private health-financing programs. Spe- The PNDS outlines several approaches to improve risk- cifically, as private insurance programs, including mutu- sharing and expand health-financing mechanisms: elles, receive subsidies and more people are required to enroll, their efficiency and financial sustainability should yy Increasingly, funds for health will be pooled through be strengthened. At the same time, contracted networks prepayment mechanisms; of providers, including private providers, will expand; contracted providers will rely less on out-of-pocket pay- 2 Based on the exchange rate from January 1, 2016, 939 Congolese ment and more on insurance schemes for their revenue. franc (CDF) = US$1. The MSP aims to create a national social production fund FINA NC ING 49 that consolidates funds from the different health financ- Mutuelles ing programs in the DRC, as described later. Mutuelles feature in the PNDS as a means for helping to achieve UHC. They are characterized by community- 6.1.3  Health-financing programs in the DRC based ownership and governance. In February 2017, the government published a law clarifying the fundamental Private health-financing programs currently have a lim- principles for organizing and governing mutuelles. How- ited role in the DRC—they cover few citizens, and the ever, mutuelles remain nascent (Mutabunga bin Lubula country is only now opening up to private insurance com- et al. 2017), with only 42 schemes in place, covering panies. Current programs include health mutuelles and around 0.4 percent of the population and amount- the organizations that support them and benefits pro- ing to 300,000 members (Mbala and Bahati 2016). A grams sponsored by employers for employees and their few community-based mutuelles have demonstrated families. Private health insurance and other health bene- potential—for example, a mutuelle in Nyantende helped fit programs are concentrated among formally employed reduce out-of-pocket payments as a proportion of people in wealthier income quintiles and reach no more health expenditure by approximately 10 percent over than 3–4 percent of the population (DHS 2013–14). five years (Soglohoun 2012). Some health mutuelles have Insurance is one financing mechanism that pools health improved their management capacity and ability to set risks and uses regular payments to reduce out-of-pocket up a scheme (see Box 23), although they still lack techni- spending by individuals for both inpatient and outpatient cal understanding of how insurance works, the necessary services. Those who have insurance pay less out-of- skills to price benefit packages, and skills to monitor and pocket for services in the DRC (Figure 31)). manage financial liabilities (Waelkens2017). Many mutu- Insurance and other health financing programs in the DRC elles face persistent external constraints, including a lack of include general and special schemes for civil servants trust and understanding of insurance; irrational provision covering all health care expenses; employer-sponsored of care, which negatively affects quality and efficiency; and schemes covering medical, dental, and surgical care for chronic health system underfunding and inability of people workers and their families; and other schemes, such as to pay for health care. (Waelkens 2017) recommend that private health insurance, including mutuelles that target mutuelles engage in broader collaboration with health sys- informal sector households (Mbala and Bahati 2016). This tem stakeholders, particularly the government, to address assessment focused on mutuelles, employer-sponsored these problems and improve access to care through regu- schemes, and other private health insurance programs. lation, supervision, subsidy, standards of care, proper use Figure 31.  Average out-of-pocket health expenditure by insurance status, 2010 70 60 Average out-of-pocket health expendtiure in constant 2010 USD 50 40.1 40 Without insurance 30 With insurance 17.3 20 8.3 10 0 Inpatient Services Outpatient Services Source: Wang et al. 2016. 50 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Scaling up health mutuelles: the grassroots experience of the Mouvement Box 23.  Ouvrier Chrétien du Congo The experience of one of POMUCO’s members, the Mouvement Ouvrier Chrétien du Congo (MOCC), illustrates the challenges of health mutuelles to scale up and be financially sustainable. MOCC is a social and cooperative movement consisting of several civil society and religious networks that promote economic development, health, and programs for women and youth. It also includes UMUSAC, whose mission is to support and expand health mutuelles for members of MOCC. UMUSAC supports health mutuelles in Kinshasa, Kitanga, Ancien Bandundu, and Orientale. It helps set up mutuelles and train managers, many of whom may be volunteers. MOCC claims more than one million members across the country, mostly in major urban areas, yet less than 200,000 participate in a health mutuelle. Each mutuelle contributes 5 percent of its revenues to a provincial federation in return for its support and to establish reserves at the provincial level. These reserves can provide some reinsurance to a mutuelle that runs a deficit. Based on experience, UMUSAC recommends a “slow and steady” approach to developing a health mutuelle, including a limited focus on primary care. It is able to offer portable benefits among its network of 60 mutuelles. On average, members contribute $5 per person per month in urban areas, with some use of in-kind contributions (for example, agricultural produce) in rural areas. Members face a 20 percent copayment for services, with some capacity from mutuelles to provide subsidies to those who cannot afford this amount. The scheme usually pays 80 percent of the claim cost. Although UMUSAC fully supports efforts to achieve UHC, it also recognizes that many barriers must be addressed before mutuelles can scale up: limited awareness of insurance among citizens and their inability to pay, adverse selection, local gov- ernment officials who are uninformed about health insurance, lack of quality health providers, lack of subsidies, and poor governance in the country. Source: POMUCO 2017 of quality medicines, and promotion of better health and membership and financial reporting and standardization financial protection for all. Demonstration cases about of systems to link with government programs (MSP 2017j). what works and does not are needed for public and pri- The second is La Plateforme des Organisations Promo- vate actors to generate lessons, as are resources to stimu- trices des Mutuelles de Santé du Congo (POMUCO), an late understanding of the value of insurance. umbrella platform for broader coordination and advocacy There are two main support organizations for mutu- in support of social protection. POMUCO was established elles in the DRC. The first, the Programme National de in 2014 by five civil society organizations (POMUCO 2015).3 It aims to build the management capacity of health mutu- Promotion des Mutuelles de Santé (PNPMS) was estab- elles and amplify their contribution toward UHC in the lished under the MSP in 2001 to promote health insur- DRC. The target population and beneficiaries of mutuelles ance through mutuelles. Key informants affiliated with vary (Table 8). the PNPMS noted that there are currently approximately 109 health mutuelles in the DRC, concentrated in Sud-Kivu, Two well-known mutuelles in the DRC are the Mutuelle de Kongo-Central, and Kinshasa. These cover approximately Santé de l’Enseignement Primaire, Secondaire et Profes- 17 percent of all health zones and 1–2 percent of the sional (MESP) and Solidarco, which are summarized later. population. The PNPMS expects to assume licensing of mutuelles (currently done by regional ministries) and to 3 POMUCO’s members include the Centre de Gestion de risques play a role in supervising mutuelles, subject to a finalized et d’Accompagnement technique des mutuelles de santé (CGAT), regulatory structure under the 2017 law on mutuelles. the Centre National d’Appui au Développement et ‡ la Participation Populaire, the Mouvement Ouvrier Chrétien du Congo (MOCC), PNPMS recognizes that the transfer of government sub- the Réseau pour la Promotion de la Démocratie et des Droits sidies to mutuelles based on member numbers and Economiques et Sociaux, the Réseau des Mutuelles de santé du their ability to pay requires improvements in systems for Congo, and the CDI Bwamanda. FINA NC ING 51 Table 8.  Population coverage of selected health mutuelles Mutuelle Targeted population Beneficiaries LISANGA Lingwala commune 94,886 2,219 MUSECCO Catholic and salvationist network teachers, other 9,000 populations of Kinshasa MESP Public sector teachers, the city of Kinshasa 193,000 Union des Mutuelles de Santé Members of MOCC, other populations of Kikwit 500,000 44,922* du Congo (UMUSAC) MAZOKS Nurses from the Kikwit-Sud health zone 576 576 MULSALKI People associated with the Bureau Diocésain des åuvres ±1,500,000 1,700 Médicales/catholiques (BDOM), the population of the city of Kitwit Kingo la Afya Karisimbi health zone 521,987 3,119 MUSSRA Goma health zone 345,007 2,145 MUSOSA Butembo city 800,000 2,619 Nyatende Nyatende zone 124,184 12,474 Walungu Walungu zone 237,398 2,738 * For the union of 12 mutuelles; paying beneficiaries only, registered = 52,053. Source: Waelkens 2017. MESP (without reserves, the scheme is not expanding; each regional expansion is estimated to cost US$1.5 million); and The most visible mutuelle in the DRC, MESP is a non- generous benefits offered by MESP covering all health ser- profit set up in 2011 to enroll all 450,000 active teachers vices at 100 percent. MESP now excludes costly services and their families. Currently, MESP operates in Kinshasa, (chemotherapy, magnetic resonance imaging, and chronic Equateur, and Katanga, covering more than 10 percent (47,000) of active teachers and their family members, diseases) to decrease claims costs. and has a current membership of around 220,000. MESP secured a government subsidy of approximately $1.20 Solidarco per person per month (approximately 40 percent of the Solidarco is a small mutuelle created by the Congolese current premium collected) to help finance its opera- diaspora with support from the BDOM and the Fondation tions. It features mandatory enrollment in regions where Belge. The organization seeks regular, predictable pre- it covers teachers, along with subsidies, both of which payments for health care in lieu of ad hoc and unverifiable are essential to scale up health insurance and contrib- requests to pay for immediate needs as they occur. Cur- ute toward achieving UHC. MESP contracts a network rently, 382 sponsors cover costs for 2,672 beneficiaries of about 81 facilities in Kinshasa, 20 in Lubumbashi, and in Kinshasa. Solidarco charges €30 per month per group 15 in Mbuji-Mayi. Approximately two-thirds of these are (up to seven people). It contracts BDOM to manage a private providers, with preference given to FBOs. MESP provider network and pay claims with a budget of €25 per pays providers a fee for service; rates are negotiated with group per month (Solidarco retains €5 for administration). each provider and reviewed every six months (MESP 2017). The cost of care for members runs at around 50 percent According to a key informant, MESP may be fragile below the €25 per group monthly payment, contrary to because of limited actuarial or financial management the experience of most other health financing programs. capacity; insufficient revenue at around $3 per person Solidarco is considering whether it should assume finan- per month; mandatory contributions paid by all teach- cial risk and administer the program directly without ers, which are used to cover only 10 percent of teachers; BDOM as a third-party administrator or whether to reduce depletion of MESP’s financial reserves of approximately rates and/or increase benefit levels. Over the longer term, $2 million because of currency fluctuation in late 2016 Solidarco recognizes that covering larger numbers of 52 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O people will ultimately require substantial and stable sub- sidies well beyond what members of the diaspora can Spotlight on a clinic’s experience Box 24.  provide (SOLIDARCO 2017). contracting with companies Doctors at a private clinic in Kinshasa noted that although Privatization of insurance in the DRC they have agreements with companies to care for their Legislation was passed in 2015 to privatize the insurance employees, the clinic sought multiple contracts at the sector, and in 2016, a presidential decree authorized estab- same time because companies were slow to make pay- lishment of an insurance regulatory body, the Autorité de ments. Doctors commented that eventually companies Régulation et de Contrôle des Assurance (ARCA). ARCA usually pay, but it is a protracted process that requires a lot of effort from both parties. At this clinic, companies paid on will oversee all aspects of the DRC’s new private insurance average $40 per family (two parents and four children) per sector, including financial requirements, reporting, compli- month. This clinic did not offer any FP products or services, ance, and consumer education. Estimates put the potential suggesting that these were not a priority for clients. market for all lines of insurance in the DRC at US$500 mil- lion, much higher than the US$80 million portfolio of the existing and single state-owned actor Société Nationale costs to providers using capitation, whereby a provider is d’Assurances (SONAS) (Wilson 2017). paid a fixed amount per person per period for a package As demonstrated elsewhere, a robust insurance sector of benefits. For some sponsors, these arrangements enables economic growth and stability—but developing function more as a prepayment mechanism, with periodic a culture of insurance, where consumers demand and reconciliation of actual costs. Often a sponsor and a pro- can obtain valued products from responsive insurance vider will agree to ad hoc negotiation of high-cost cases. providers to help them manage risks, takes time. ARCA The type and amount of health benefits provided by com- is expected to begin issuing licenses for private insurance panies vary. According to a key informant, companies pro- companies to operate in the DRC in early 2018. Infor- vide varying levels of health care and do not typically cover mants for this assessment stated that regional and global serious illnesses. Companies also provide different levels insurance companies, as well as local companies such as of coverage for primary care services, with some capping banks, are cautiously optimistic about the potential to coverage or choosing to exclude specific services (for enter the private insurance market in the DRC. They con- example, maternity care and FP—one informant suggested sistently mentioned that SONAS has a poor reputation in that these services are “not related to an illness”). Although the DRC and is widely believed to “not pay claims.” As a some schemes offer the same benefits for all employees, result, new entrants to the insurance market will need to others offer additional benefits to managers (for exam- demonstrate the value of insurance to a public that may ple, for medical evacuation or services outside the DRC) have negative perceptions. At this early stage, ARCA or cover only services that are obtained in the employee’s does not have an articulated plan for how it will regulate home province (or in the DRC). This limitation effectively private health insurance, including for unregulated mutu- excludes high-cost tertiary care that may be delivered only elles and other community-based schemes that target outside an area. One key informant observed that to limit low-income and informal populations (ARCA 2017). costs, a company may choose to terminate an employee who incurs high health care costs. Employer-sponsored health programs Employers are required by law in the DRC to provide health Third-party administrators benefits to employees and their families. Employers, partic- International and local TPAs develop and manage provider ularly in remote work sites, may provide on-site health ser- networks, and some broker insurance through foreign vices. In urban areas, they typically contract, either directly insurers. Many corporate sponsors use a TPA to administer or through a third-party administrator, with a health care their health benefits. TPAs that were interviewed indi- provider or network of providers (see Box 24). Some cor- cated that private providers often deliver better quality porate programs transfer financial risk of employee health of care but raised concerns about challenges to manage FINA NC ING 53 fraud and moral hazard. Two examples of private organi- (actual costs are closer to $25 per person per month). zations brokering health benefits and TPA services in the LISUNGI pays providers by advancing them 80 percent DRC are described here. of the premium, retaining 20 percent for administration. Providers can keep any unspent premium, but when Global Access Health Network health costs exceed the premium received, they nego- The Global Access Health Network (GAHN) is a DRC sub- tiate with LISUNGI and its corporate clients to authorize sidiary of a South Africa-based joint venture between additional funds for that patient (LISUNGI 2017). Medical Services Organization International and Axi- health. GAHN manages health benefit programs and Performance-based financing coordinates international medical evacuations when needed. Approximately 60 percent of GAHN’s business is The MSP, with support from the World Bank, USAID, and through direct contracts with eight corporations compris- other donors, has gained experience with performance- ing 3,000 employees plus family members; the remaining based financing (PBF), and in 2011, the DRC govern- 40 percent of GAHN’s business is through international ment with its partners harmonized PBF approaches (see insurers, such as Aetna International, Bupa, and AXA. Box 25). A number of PBF strategies aimed at improving Foreign insurance contracts are permitted in the DRC upon acceptance by the state insurer, SONAS, of an application for the policy and payment of a fee equal to Box 25. Performance-based financing 5 percent of the premium. GAHN sees the impending pri- in the DRC vatization of the insurance sector as a big opportunity but has adopted a wait-and-see attitude (GAHN 2017). The World Bank–funded Health System Strengthening for Better Maternal and Child Health Results project (Projet de Développement du Secteur de la Santé; PDSS) was intro- LISUNGI duced in 2014 and scaled up in 2016, and is now a supply- LISUNGI is a local broker that partners with Oracle Health. side effort to improve utilization and quality of MCH In Kinshasa, LISUNGI covers around 7,700 families. Most services in 11 provinces in the DRC. Administered through of these are part of a low-cost government scheme; provincial purchasing agencies contracted by the MSP, it about 700 others are covered by 20 to 25 corporate provides incentives for public and private health centers sponsors. In Katanga, LUSINGI works with about 50 cor- to provide quality services and for health center adminis- porate clients comprising 3,000 families; an additional trations to consolidate and improve their governance and 600 to 700 families are covered under the government accountability. The project also provides additional incen- scheme. The company is growing at about 3 percent per tives under a community PBF scheme to stimulate demand month, and adding two new corporate clients per month through household visits conducted by the CODESA. PBF in Katanga. LISUNGI Lubumbashi offers five benefit plans incentives are paid quarterly upon verification. They can be used by the CODESA to support operations or other at different price points, ranging from US$25 to US$90 community health projects and to incentivize CODESA per family (up to six) per month to corporate clients; members to conduct community service (World Bank n.d.). most clients chose the second least-expensive option (US$35 per family per month). This option covers medical A study from the DRC suggests that the design and implementation of PBF schemes in a fragile and frag- consultations for general services, obstetrics and gyne- mented financing environment is critical and should be cology, and pediatrics, plus simple surgical procedures embedded into larger health system reforms (Fox et al. such as hernia repair. Essential medicines are covered, 2014). The study found that PBF incentives paid to with basic services for laboratory, radiology, and obstet- workers in Katanga Province to offset lower user fees ric ultrasound. FP services are not explicitly listed in the may not motivate health workers when it requires benefit package but may be covered under the broader them to assume an increased workload. Although health categories of care mentioned. LISUNGI offers a low-cost worker salaries might be low and delayed, workers were option to government employees that costs $20 per month satisfied to not receive them, perhaps because of the dis­ per family ($10 from the employee and $10 as a sub- status the salary infers. sidy from the government). This product is a loss leader 54 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O service quality, increasing the availability of services, and healthy workforce. The amount of coverage provided by improving MCH outcomes have been tested. Results are corporate sponsors can vary from basic to comprehen- mixed and underline fragility in the health system (World sive levels. Bank n.d.). Although programs to date have largely In developed countries, private health-financing schemes focused on improving public health system performance, have evolved over time alongside government schemes stakeholders indicate that about 20 percent of partici- (Kimball et al. 2013). In many low- and middle-income pating providers are in the private for-profit or FBO sec- countries in Africa and Asia (see Box 27 for example from tors. Informants indicate that outcomes depend on the India), simple private health insurance products com- design of incentives, availability of sufficient funding, and plement public programs. These products pay a fixed gaining sufficient stakeholder support. Emerging lessons amount to clients who are hospitalized to offset indirect from PBF schemes that engage community actors to costs of care (for example, for transportation or to replace increase access (or even provide) health services show lost wages). Such products include Caregiver, a product the importance and role of program components, such as offered to clients of Microfund for Women, a microfinance training, monitoring, timeliness of payments, and engaging institution in Jordan, and underwritten by Jordan Insur- community counterparts (Falisse et al. 2015). The over- ance Company (Women’s World Banking 2012). all success of these initiatives and how to improve them Community-based schemes, mutuelles, in Francophone deserve further research. countries are often a first foray into health insurance. Even- tually these may merge into a government-sponsored Relevant lessons learned 6.1.4  program that uses subsidies to scale up coverage and from global experience provides capacity building and regulation, as occurred in Ghana (see Box 26). Private schemes also contribute by To expand population and service coverage and provide leading innovation and testing new products and busi- adequate financial protection, health insurance schemes ness models. Elsewhere private actors have catalyzed that aim to contribute toward UHC require adequate and new technology, especially mobile phones, to distribute stable government subsidies, scale (through mandatory enrollment), and improved efficiency. These requirements are reflected by the experience of government-sponsored programs, such as Ghana’s National Health Insurance Learning from Ghana: Mutuelles as a Box 26.  Scheme. Ghana’s scheme also demonstrates the impor- foundation to advance toward UHC tance of offering a benefit package that the scheme is able to finance and closely monitoring scheme perfor- Since the launch of community-based health insurance mance so that timely action can be taken when needed schemes in Ghana in 1999, coverage in the country has to mitigate operating deficits. scaled up in two phases. First, schemes proliferated organically throughout the country, motivated by com- Global experience shows that purely voluntary, private munity solidarity, increasing from three schemes in 1999 health insurance schemes offered by licensed insurance to 258 by 2003. Despite limited coverage, this fostered companies and community-based schemes (such as a culture of health insurance. In 2000, Ghana passed mutuelles) are not scalable or self-sustaining and do not the National Health Insurance law, which ordered a new contribute materially to UHC (Kimball et al. 2013). How- health insurance scheme with a standard benefit pack- ever, private health insurance has a role in a country’s age to be set up and administered at the district level. health-financing efforts because no government can pro- This melding of existing community-based insurance vide all services to everyone for free. Usually voluntary capacity with a top-down, national framework increased private health financing is an option for limited numbers population coverage rates 30-fold over a relatively short of affluent clients who can afford to pay for better pro- period of time, reaching the present coverage of more tection and access. In addition, formal sector households than 40 percent. may benefit from employer-sponsored health coverage— Source: Adapted from Atim 2010, and Joint Learning Network in the DRC, employers are mandated to provide bene- 2012. fits, and they may be motivated by a desire for a stable, FINA NC ING 55 and their clinical and service standards vary widely. Learning from India: enabling Box 27.  Administrative know-how is basic. inclusive private health insurance Recommendation: Strengthen readiness of private providers to participate in mutuelles and other health- India’s experience in privatizing its insurance sector financing initiatives by developing a viable network of in the 1990s may shed light on options for the DRC to providers who commit to common quality and pricing consider. Today, India has a robust private insurance and treatment standards and can share financial risk with market, with more than 50 licensed general and life programs, including mutuelles; and establishing a partner- insurance companies. Notably, the Insurance Regula- tory and Development Authority, established in 2000, ship between a private provider network and a corporate stipulates that private health insurance companies sponsor of a health benefit program. must invest 2 percent of their profits, increasing to 5 percent after three years, in the rural sector and Identify the role of PBF in improving the performance also serve increasing numbers of vulnerable clients to spur financial inclusion for underserved populations. The of private providers Authority implemented microinsurance regulations in Finding: The DRC and the larger global community are 2005 and again in 2015 to improve the enabling environ- learning whether and how PBF can improve the perfor- ment for insurance providers serving low-income clients. mance of a health system. To date, results of PBF programs A key lesson is that one size does not fit all. For exam- in the DRC have been mixed, possibly in part because of ple, insurance programs for low-income clients do not the fragility of the health system. These programs have require the same level of financial reserves as programs largely excluded private providers while focusing on the with greater claims exposure or the same rules to license public sector. insurance agents. More generally, India’s experience demonstrates that government can catalyze investment Recommendation: Validate successes and challenges in insurance for low-income consumers by setting up a of PBF programs in the DRC and summarize how these favorable enabling environment that includes incentives programs are evolving and the extent to which they have and reasonable rules. engaged private providers. Test whether and how PBF Source: Insurance Regulation and Development Authority of India. programs can more fully engage private providers to deliver more-efficient, higher-quality services. 6.1.5.2 Strengthen and clarify the role of mutuelles and administer insurance in more efficient “low touch” Increase engagement of mutuelles and ways. An example of this is Antoka, the simple mobile- other health-financing mechanisms enabled insurance product relaunched in Madagascar in 2016 by Airtel and Allianz (Midi-Madagasikara 2017). Finding: The DRC plans to scale up coverage in community-based mutuelles and other mechanisms, such as mandatory health insurance for civil servants, but has 6.1.5 Recommendations had limited success in doing so. Recent enabling legisla- Recommendations in health financing include the tion and strengthened structures to support mutuelles following. should accelerate health coverage over time. Research suggests that collaboration with a broader range of stake- holders, including government and private actors, remains Include private providers in national 6.1.5.1  a critical gap (Waelkens 2017). health-financing initiatives Recommendation: Establish an advocacy forum for mutu- Strengthen private providers’ ability to participate elles and other health-financing mechanisms to engage in health-financing initiatives government and other key stakeholders (for example, Finding: Private providers have limited experience and civil society, employers) in implementing and monitoring know-how in working with health-financing programs, adherence to common performance standards, focusing 56 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O on clinical care (including use of medicines, service mix, such as microfinance institutions, associations, or pricing and billing practices, reporting, and patient ser- cooperatives (agri-workers), with the capacity to vice standards). enroll and collect contributions from members. yy Support expansion of strategic purchasing for health Build on lessons from existing financing programs—contracting, provider payment health-financing programs mechanisms, and monitoring. Finding: A few of the DRC’s health-financing programs yy Develop and test models for quality assurance of have had some degree of success. For example, although contracted providers, entailing accreditation, site the scheme remains fragile, the MESP has demonstrated assessments, audits, and routine monitoring. potential in accessing government subsidies and imple- yy Explore ways to use technology (for example, bio- menting mandatory contributions. metric identification cards or mobile-enabled trans- Recommendations: actions) to improve the efficiency of health-financing programs. yy Document and disseminate lessons learned from existing health-financing programs and develop a yy Support a TPA or employer sponsor to develop stronger demonstration case for coverage. and scale up an improved model to administer an employee benefit program, with improved product yy Investigate how existing health-financing programs design, pricing, provider network, payment mecha- can be scaled up and financially sustained in the DRC nisms, and claims management. context, and provide technical assistance to these programs to address current challenges (for exam- ple, revising benefits and pricing). Work with health-financing programs to cover FP and preventive services Strengthen health-financing programs Finding: Most health-financing programs (including Finding: Some health-financing programs are adminis- mutuelles and employer-sponsored ones) focus on tered by TPAs, whereas others are administered by the curative care and not preventive services such as FP. sponsor (for example, mutuelle or employer sponsor). For example, although most programs cover maternal Payment arrangements and administrative processes are services surrounding pregnancy and childbirth, they may largely ad hoc and manual. For example, current pricing not cover postpartum FP. Increased access to FP can of benefit packages covered by programs varies widely prevent unplanned pregnancies, lead to fewer and lower- and may be actuarially unsound. Programs usually pay risk pregnancies, and help achieve broader development with a fee-for-service plan and struggle to manage the goals. Covering FP can be a cost-effective investment for risks of moral hazard and fraud. In some cases, programs sponsors of health-financing programs. share financial risk with health providers by paying per Recommendation: Collaborate with mutuelles and cor- capita rates, but often these are adjusted on a case-by- porate sponsors to cover FP and broader preventive ser- case basis. vices by assessing coverage of FP and other preventive Recommendations: services by main health-financing programs and develop- ing a business case and advocacy material for investment yy Support organizations, such as le Centre de Gestion in (covering) these services. des Risques et d’Accompagnement Techniques des Mutuelles de Santé, to build capacity of mutuelles and other health-financing programs in areas such as Develop a culture of insurance product design, pricing, and risk management, and Finding: The DRC lacks a culture of insurance among strengthen back office operations, such as enrollment, its citizens, limiting demand and understanding of the premium collections, and claims management. role it can play. Changing this norm requires continuous, yy Test models for scaling mutuelles and other health- long-term investment in consumer education. The newly financing programs in partnership with aggregators, established regulator, ARCA, is nascent—its regulation and FINA NC ING 57 stewardship of private insurers and the impact on private of skilled labor, difficulty enforcing contracts, political service providers working with insurers have yet to be uncertainty, a weak judicial system, and limited access tested. More specifically, it is unclear how ARCA intends to capital. However, the government of DRC is working to oversee community-based mutuelles or other insur- to improve the business climate. In 2014, the DRC joined ance programs that target low-income households. It is the Organization for the Harmonization of Business Laws also uncertain how ARCA will educate the public about in Africa (OHADA). OHADA provides multiple incentives insurance, and this will link to broader efforts promoting for foreign investment by standardizing and streamlining social protection and resilience. enterprise creation and contract enforcement as well Recommendations: as providing investor protection and harmonization of accounting principles. Moreover, investment reforms and yy Collaborate with ARCA to educate consumers about investor protections make PPPs more secure and attrac- health insurance (for example, conduct media cam- tive for outside investors. Current investment regulations paigns to inform consumers that health insurance prohibit foreign investors from engaging in informal small can be a valuable way to be protected against cata- retail commerce, referred to locally as petit commerce strophic costs for health care). (U.S. Department of State 2016). yy Collaborate with ARCA to engage insurance compa- FDI in the DRC has been falling in recent years (Table 9). nies, mutuelles, health providers, and other actors, FDI in the DRC reached a peak of US$3.3 billion in 2012 but such as the Federation Entreprises du Congo or the fell to US$1.2 billion in 2016 (World Bank 2017c). A more ASPS in support of enabling regulation and supervi- stable political environment could present new opportuni- sion of private sector health insurance stakeholders. ties for foreign investment in the future. yy Collaborate with a private insurer to pilot an insurance The DRC’s financial sector comprises 19 licensed banks program that targets informal, vulnerable groups; and 120 microfinance institutions (MFIs) and cooper- complements government-sponsored services; con- atives (export.gov 2017c). Their presence is unevenly tributes to building awareness of the potential value distributed across the territory, as shown in Figures 32 of insurance; is simple and modeled on the Care- and 33). giver or Antoka products described earlier; and focuses on coverage of incidental costs to access The five largest banks hold about 65 percent of bank hospital services. deposits and 60 percent of total bank assets (Inter­ national Monetary Fund 2014). Banks hold 90 percent of deposits, and MFIs hold the rest. There are roughly 6.2  ACCESS TO FINANCE $3.6 billion of deposits in the banking system but an Overview of the supply of financing— 6.2.1  estimated $10 billion of savings exist outside banks. The the banking and microfinance sector DRC has one of the lowest bank penetration rates in All businesses in the DRC face challenges, including the world—only 11 percent of the population has a bank fragile infrastructure, lack of transparency, shortage account (World Bank 2017f). According to the Congolese Table 9.  Foreign direct investment, net inflows as percentage of GDP 2012 (%) 2013 (%) 2014 (%) 2015(%) 2016 (%) DRC 12.06 6.99 5.42 4.62 3.77 Low-income countries 5.73 5.20 4.16 4.17 4.53 Sub-Saharan Africa 2.45 2.39 2.41 2.71 2.56 Organisation for Economic Co-operation and 2.43 2.28 1.74 2.95 3.06 Development (OECD) members World 2.72 2.56 2.20 3.04 2.92 Source: World Bank 2017c. 58 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Distribution of banks Figure 32.  Distribution of MFIs Figure 33.  (percentage of total number (percentage of total number of branches and bank windows) of branches and MFI windows) Source: Altai Consulting 2016. Source: Altai Consulting 2016. Association of Banks (Association Congolaise des Ban- lect deposits (Banque Centrale du Congo n.d.). Financial ques), an estimated 65 percent of the population has institutions are generally concentrated in the eastern savings, but only 4.7 percent of these save at a bank part of the country, although larger banks and FINCA (export.gov 2017c). Family members and friends are the have branches in most major cities. Many MFIs and main source of loans in the DRC, followed by private savings and loan cooperatives (coopératives d’épargne informal lenders who may not be trustworthy or may et de crédit) operate only in the province in which they have higher interest rates. See Figure 34. are based. The Central Bank lists authorized MFIs and The Foundation for International Community Assistance cooperatives in only seven provinces (Banque Centrale (FINCA) is the only microfinance institution currently du Congo n.d.). listed on the Central Bank’s website as being in the reg- Agent banking is a growing channel, providing finan- ulatory category authorized both to make loans and col- cial services to remote or underserved populations. For Figure 34.  Borrowing by source (age 15+), 2011 35% 30% 30% Percent of Loans by 25% Source 20% 15% 10% 7% 3% 5% 2% 1% 0% Financial Private informal Store by buying Employer Family or institution lender on credit friends Source: The World Bank 2017. FINA NC ING 59 example, almost 60 percent of all of FINCA’s transactions Role of financial institutions 6.2.2  are through agents. FINCA does not charge clients for in the private health sector transactions but aims to cover costs through balance Most private health care providers in the DRC are con- sheet growth. FINCA is also exploring agent incentive sidered micro, small, or medium enterprises (MSMEs). mechanisms, such as expanding services offered by To expand and improve the services offered, providers agents (for example, payments and other transfers) to need access to financial resources. In many countries, increase revenue sources (MasterCard Foundation and financial institutions are not accustomed to thinking of BFA March 2017). private health providers as businesses. However, banks The number of active mobile users in the DRC is grow- interviewed during this assessment stated that private ing based on data provided by network operators offer- health providers are eligible for loans under the same ing mobile money services. Given the DRC’s large rural conditions as any MSME, and banks are willing to con- population and concentration of financial institutions in sider health care businesses as potential borrowers. urban centers, mobile money offers significant poten- Unfortunately, Congolese MSMEs in general face a tial. However, those with mobile money accounts rarely number of well-documented constraints in accessing use them; in 2016, only 600,000 of 6.8 million registered financing; for example, loan maturities are frequently mobile money users accessed their account in the previ- limited to six months or less, with interest rates around ous 90 days (Figure 35)) (CENFRI 2016). 16–18 percent. Banks avoid longer-term loans because of Consumers currently lack understanding about how weakness in the legal system and difficulties obtaining mobile money products work, limiting their uptake interbank financing (export.gov 2017c). Table 10 sum­ (Finmark Trust et al 2015, GSMA 2013, Élan RDC 2015). marizes demand- and supply-side barriers to financing for MSMEs in the DRC. This is exacerbated by poor quality network coverage and limited coverage of the mobile agent network (Élan During interviews, financial institutions described their RDC 2015). As a result, mobile money needs to gain more credit products available to health MSMEs, including market share to be an effective digital tool in accessing loans for working capital, assets or equipment, and real health services and products as well as contribute to estate or construction (see Box 28). Loan terms are resilience to health shocks by expanding accessible net- generally 12 to 60 months, and annual interest rates are works for credit. 10–36 percent (averaging 15–25 percent). Most banks ask for collateral—usually property title—for loans over US$10,000 and require the title to be registered (that is, Figure 35.  Use of mobile money accounts an official mortgage) for loans over US$30,000. Banks in the DRC, 2016 seek collateral value of 120–200 percent of the loan amount. Although health care businesses are eligible for MSME financing, the health sector makes up a small portion (between 1 and 5 percent) of the current loan portfolio of the banks interviewed. Reasons include: 6.8m yy Weak business and financial management skills of Registered mobile money users health providers, who are unable to provide financial statements or account history to prove repayment capacity; yy Issues with accepting a mortgage on a hospital because it would be socially impossible to repossess ~600k Active or a lien on specialized medical equipment, which may users not have a strong resale market; and yy Difficulties verifying health facility registration or Source: CENFRI 2016. ship status, making it impossible to ascertain owner­ 60 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Demand- and supply-side barriers to engagement of micro, small, and medium enterprises Table 10.  by financial institutions Demand-side: MSMEs Supply-side: financial institutions yy Assume the MSME segment means high costs for loan yy Do not know the criteria for accessing loans. analysis and administration and lower credit volume, which yy Lack understanding of financial terminology. is less attractive. yy Do not seek the “best deal” by comparing institutions yy Lack transparency on credit conditions, with no explana- to identify the best terms. tion for rejecting or delaying MSME loan applications. yy Think they need to pay high taxes and expose them- yy Have a low tolerance for negotiating with MSMEs or adapt- selves to informal facilitation fees if they get a loan ing to their needs because the amount of credit provided is equal to or larger than US$10,000. not significant. Source: Shwarz 2011. whether the facility has the authority to borrow has identified in lending to the private health sector as money. an MFI. MFIs offer smaller loans (from US$20 to US$150,000 for one MFI interviewed), with higher interest rates (24–60 per- 6.2.3  Demand for access to finance cent per year) and shorter loan terms (3–36 months). Of Many private health facilities in the DRC are self-funded, the four MFIs interviewed, two provided incidental lend- often starting with an initial investment from the owner ing to the health sector, whereas two had specialized or a loan from a family or friend. Providers who were (but limited) health lending activities. interviewed said it was difficult to access formal financ- Vision Fund, a partner of World Vision, provides ing and mentioned high interest rates, significant collat- microloans to support activities previously funded by eral requirements, and restrictively short loan terms. The World Vision. Vision Fund currently has a portfolio of a Order of Pharmacists said that banks were concerned few hundred health loans, with the majority being to that pharmacies were not profitable given the large pharmacies. Table 11 summarizes the issues Vision Fund number of outlets, and some FBOs and nonprofits said commercial banks would not lend to not-for-profit enti- ties. Providers also mentioned not understanding what information was needed to prepare a loan proposal. Snapshot of two health loan Box 28.  Health care businesses are typically run by clinicians portfolios who often lack business and financial management skills, making it more difficult to assess the potential return on Two banks interviewed stated that health loans made investment or present successful loan requests to banks up roughly 2 percent of their total loan portfolios. In one and MFIs. In Senegal and Madagascar, after receiving case, two or three large health borrowers make up about business training and coaching through USAID’s Sustain- half of the bank’s health loan portfolio. Another bank ing Health Outcomes through the Private Sector (SHOPS) stated that its health loans are concentrated in Kinshasa Plus project, providers have been able to improve their and Lubumbashi, with most loans being for real estate or construction, followed by working capital and equipment book-keeping and cash management sufficiently to save loans. One bank indicated that generally, small provid- and invest in new equipment and obtain loans for addi- ers request loans for equipment and working capital, but tional expansion. pharmacies may seek larger loans. Some providers know about the availability of credit from Source: 2017. Primary Data. DRC: Field Interview. financial institutions and have been successful in obtain- ing loans (Box 29). Private providers in Lubumbashi may FINA NC ING 61 Table 11.  Private health sector lending issues Strengths Stable activity, health care practices usually exist for a long time compared with other types of activities, and owners are easy to find. Weaknesses Difficult to authenticate the owner of the activity because many pharmacies and health centers register as an NGO, sometimes illegitimately. The law stipulates that activities related to the health sector are carried out only by technicians and specialists in the sector, which is not the case; merchants who embark on these activities pay “rights of sponsorship” to specialists to obtain licenses to operate. Providers have small margins and profits, especially small pharmacies that have slow inventory turnover because of competition from traditional practitioners and self-medication. The relationship between quality and price is still not balanced. When quality services are not provided, negative communication spreads in the community, and the health center will lose business. In addition, health centers are often located in places where the community has weak purchasing power. Financing risks Providers can be subjected to tax penalties if the activity does not have all the required authorizations. Penalties could be significant, which may lead to nonrepayment of loans granted. Sponsorship payments can be significant, affecting the operator’s revenue and making repayment difficult. The minimum sponsorship amount is $500. In addition, there are some sponsors who require payment every month, threatening to withdraw their authorization number otherwise. Some hospitals are denied the right to operate when health inspectors discover that unauthorized activities are taking place, and the owner is at risk of being imprisoned. Uncertain profitability and difficulty in ensuring cash flow. Source: Vision Fund 2017. face slightly different challenges to those in other cities. high level of competition. Facilities such as the Centre The economy in Katanga is linked to the mines and Médical du Centre Ville have been able to negotiate rea- foreign-owned companies, most of which contract with sonable prices and keep their corporate clients based on medical centers to provide health care for employees. the quality of their services. This has led to a proliferation of medical centers, with Lack of access to financing negatively affects health pro- some guaranteed revenue from their corporate contracts. viders in several important ways. Without financing, pro- However, they still struggle to be profitable given the viders struggle to make quality improvements or expand Box 29.  Examples of financing Clinique Medécin de Nuit (Kinshasa) has taken out three bank loans each for equipment purchases, with interest rates at national Bank for Africa in Congo for working capital and now has access to private 33–40 percent. It has borrowed from Inter­ equity through an IFC program. Centre Médical du Centre Ville’s (Lubumbashi) first loan was for the construction of a new site. They have taken out several major loans, including a current loan for a large site expansion. The loan term is three years, at 25–26 percent interest, with the title to the property and inventory as collateral. The Centre considers the loan size and three-year limit to be too constrictive and said that the Centre occasionally has experienced repayment problems and had to pay penalties. Health Centre Kalebuka (Lubumbashi) autofinances some of its operational costs by selling water at the pump inside the compound, which was installed by World Vision. The income from this side business helps the center ensure it has permanent electricity. 62 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Box 30.  Health enterprise and innovation Encouraging business creation and innovation has become a priority in the DRC, and President Kabila sees small business as the motor of the economy (ACP 2016). In September 2017, the Minister of Small and Medium Sized Enterprises announced an experiment with business incubators to accelerate business growth and job creation in key economic sectors (ACP 2017a). Several business incubators have opened to help start-ups thrive. The I&F Entrepreneuriat incubator in Kinshasa provides business plan assistance and supports new companies and entrepreneurs (ADIAC 2014). In addition, the African Develop- ment Bank Private Sector Operations and the Fund for African Private Sector Assistance (FAPA) are supporting Advans Banque Congo to provide loans and financial services to small and medium scale enterprises in Kinshasa (AfDB 2013). Kivu Entrepreneurs, a business incubator in Goma, provides business plan assistance and training to young entrepreneurs (Kivu Entrepreneurs n.d.). These new initiatives rarely include health entrepreneurs. Social enterprises in the health sector are distinct because they seek to operate on a sustainable basis while achieving social impact. This often means targeting low-income or otherwise under- served populations, seeking to address barriers these populations may face in accessing health. This can mean developing new business models that can scale in low-income markets. If these enterprises can demonstrate the potential for sustainability at scale, this creates an opportunity for private investment capital to enter the market and contribute to increased access to and usage of priority health services. Successfully reaching investor readiness requires that enterprises have access to appropriate sources of capital and technical assistance to enable innovation, experimentation, and learning. Health enterprises may also need assistance in addressing barriers, such as a challenging regulatory environment, shortage of available and qualified talent, or a lack of suitable partners. Health enterprises must rely on a strong ecosystem of supporting organizations that can address these scaling barriers. In the DRC, the ecosystem that supports scaling of health enterprises is nascent. Accessing financing is challenging for entrepreneurs. Commercial lending rates are high, making it extremely difficult to access the type of capital necessary to start and grow a business. One promising social enterprise is Asili, a start-up cocreated by the American Refugee Committee and supported by USAID and international partners. Asili looks like a strip mall with a health clinic, a clean water distribution system, and an agricultural cooperative for farmers grouped together. Services are linked through a monthly membership, allowing members access at reduced prices (ARC n.d.). their practice. Equipment financing is also challenging— 6.2.4 Recommendations many hospitals and clinics in remote areas lack the funds Provide business and financial management training to purchase and maintain necessary medical equipment and counseling for private health providers for quality care (export.gov 2017d). Because of difficulties Finding: In addition to the weaknesses noted in the Health maintaining imported equipment, in particular, machines Workforce section, health providers often have weak can quickly become unusable. Providers shared stories business and financial management skills and are gen- of complicated financing arrangements with European erally unable to provide financial statements or accounts suppliers with effective interest rates as high as 86 per- history to prove repayment capacity. These management cent. Although financing from friends and family is import- weaknesses can be detrimental to health outcomes in ant, it is limited, thus restricting growth in the private various ways. For example, poor inventory management health sector. leads to stockouts, and lack of access to finance can limit An important potential resource is the ASPS, which is the growth of the health facility and thus limit the num- seeking ways to offer the highest-impact support to ber of patients it can serve. Basic business and financial private health providers. The ASPS could also be an management training can help improve the overall via- important partner in helping expand financing for its bility of a private health practice and enable providers to members. access financing. In addition, business counseling helps FINA NC ING 63 reinforce key learning and can support implementation institutions to lend to health care businesses, such of recommendations, including accessing financing. as local pharmaceutical manufacturing businesses Recommendations: or wholesalers, who do not meet standard collateral requirements. This could also include a loan guaran- yy Offer business training courses to private health pro- tee fund to encourage the expansion of drug outlet viders, covering topics such as business and financial networks, as mentioned in the Access to essential management and reporting, marketing, inventory medicines section. management, financial literacy, and access to finance. yy Explore options to identify medium- or longer-term yy Provide individual, one-on-one counseling for selected funding to assist banks to grant longer-term loans providers who demonstrate the highest potential for that better meet the financing needs of the health implementing changes and growing their practices. sector. yy Coordinate business training and counseling with clin- yy Support financial institutions to reduce costs of lend- ical training and accreditation steps recommended in ing to the health sector. Assist financial institutions the Health Workforce section to reinforce the overall to conduct process evaluations to improve efficiency quality of health businesses in the DRC. by identifying and addressing operational weak- nesses to reduce overall costs. Work with financial institutions to expand lending to yy Work with financial institutions to develop financial the health sector and increase private providers’ access products adapted to the health sector. to capital yy Provide training, information on the private health Finding: It is difficult for many private health providers in sector, and technical assistance to financial institu- the DRC to access formal financing, and providers who tions. This could include topics such as supporting are able to borrow from banks and MFIs may face sig- the evaluation of business opportunities in the private nificant collateral requirements, restrictively short loan health sector and market segmentation or marketing. terms, and high interest rates. Providers’ available collat- eral may be insufficient or unacceptable. Establish partnerships to increase access Recommendations: to finance for key investments yy Establish a risk-sharing mechanism or mechanisms, Finding: Lack of financing can have a negative impact on such as a USAID Development Credit Authority port- a private health practice, such as preventing health busi- folio guarantee (see Box 31), to encourage financial nesses from obtaining and properly maintaining medical equipment. It can also limit the private health sector’s abil- ity to make quality improvements to better serve patients, USAID Development Credit Authority Box 31.  grow their health facilities to reach more patients, or (DCA) Guarantee develop new facilities. Partnerships between equipment suppliers and banks can develop (for the bank) a pipeline A DCA is a guarantee that is backed by the full faith and of clients needing loans to purchase equipment and (for credit of the U.S. Treasury. It typically covers 50 percent the supplier) a source of financing. of the loan principal (not fees or interests) for term loans. The DCA has the flexibility to guarantee local or foreign Recommendation: Evaluate the potential to develop part- currency. Preapproval is typically not required for indi- nerships and market links within the health ecosystem vidual loans placed under the DCA. Guarantees may be that would generate benefits to all parties. paired with USAID or other technical assistance projects that can strengthen the borrower’s ability to repay and support the financial institution’s lending capacity in a Link health to health enterprise new sector. and innovation activities Source: USAID 2018. Finding: There are few organizations in the DRC posi- tioned to provide technical assistance to health enter- 64 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O The Nigeria Health Innovation Marketplace Box 32.  The Private Sector Health Alliance of Nigeria (PHN) successfully launched the Nigeria Health Innovation Marketplace (NHIM), a platform for key actors in the country’s healthcare innovation ecosystem. The NHIM’s objectives are to identify promising innovations, incubate and create links that will enable scale, build a sustainable convergence platform around health innova- tion, and invest for impact in selected opportunities. It offers a variety of services, including an innovation hub, competitions and hackathons, a data and knowledge repository, an innovation map, and innovative partnerships. The NHIM has 799 inno- vators, 20 investors, 423 medical professionals, academia, NGO, and other participants. Sources: NHIM 2018; PHN 2018. prises that would enable them to be investor ready, and and help identifying investors and growing to scale. As current incubator efforts do not focus on health. part of the assessment, priority health areas could be Recommendation: Assess the landscape for health enter- identified, such as health technology or medical devices. prises and determine the most promising activities to A health enterprise conference in Kinshasa could build jump-start health companies, potentially including a seed on the innovation activities in other sectors (see Box 32 fund for promising entrepreneurs, technical assistance, for example from Nigeria). FINA NC ING 65 7.  Health Workforce There is little publicly available data on the size and scope of the private health workforce in the DRC. However, the data that are available and anecdotal evidence suggest that the private sector trains and employs a large number of health workers. This section explores private training institutions and the number of private health sector workers by cadre. 7.1 DEVELOPMENT AND REGULATION information about health workers trained in either the OF THE PRIVATE HEALTH WORKFORCE public or private sectors. As a result, the amount and quality of available information vary by province. The public sector plays a significant role in the devel- opment, supervision, and regulation of the private health workforce. Important organizations include the Ministère Secondary-level institutions de l’Éducation Nationale, Ministère de l’Enseignement Secondary-level institutions train birth attendants, phar- Supérieur, Ministère de Commerce, and local provincial macy assistants, physiotherapy assistants, nurses, com- governments. There are multiple private sector actors munity health staff, medical laboratory technicians, and involved in the regulation of HRH. Cadre-specific orders other health technicians. According to the 2017 HRH are responsible for ensuring members respect ethics rules Yearbook of the DRC, there are 477 secondary-level and advocating for the medical profession. In addition, institutions (Table 12). Seven of 10 of these are managed health unions and associations are key stakeholders in the by a private institution, either FBOs or other private development, implementation, and evaluation of HRH pol- organizations, and just under one-third are managed by icies. These organizations seek to address issues related the state (30.4 percent) (MSP 2017i). to improved remuneration, development of professional The number of institutions grew significantly between career profiles, integration of new HRH job positions, and 2013 and 2017, with 71 opening in the last three years, improved health worker safety. They are also involved in and of these, 55 were in the private sector (nine FBO and efforts to develop an inventory of all HRH in both the 46 privately managed). Secondary-level institutions are public and private sectors. distributed across all provinces. The three provinces with the most training institutions are South Kivu (54 schools), 7.2  PRIVATE MEDICAL TRAINING INSTITUTES Kinshasa (53 schools), and Kwilu (34 schools). The avail- 7.2.1  Types of training institutions ability of different training programs varies significantly. There are three main types of training institutions in the Nursing training is offered by 95 percent of secondary- DRC: secondary education institutions (Institutions de training institutions; only 6 percent and 5 percent train formation du niveau secondaire), higher education insti- birth attendants and laboratory technicians, respectively tutions for technical medicine (Institutions supérieures (MSP 2017i). Of the 29,054 students enrolled in these de techniques médicales), and universities with faculties institutions, 18,142 graduated with a secondary school of medicine and pharmacy (universités avec des facultés diploma between 2008 and 2013, a graduation rate of de médecine et de pharmacie). Under the government’s 62.44 percent (ONRHS-RDC 2015). Because of the rapid decentralization reforms, medical training institutes fall growth of these and other training institutions, provin- under the control of provincial governments, and there cial governments have had trouble monitoring the per- is no centralized data repository or process for sharing formance of these schools, including the total number of 66 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Secondary level institutions Table 12.  programs include nursing, management of health insti- by ownership and province tutions, laboratory management, imaging, physiotherapy, nutrition, community health, hygiene and sanitation, Ownership pharmaceutical technician, and midwifery. Province Public FBO Other Private Total There were 128 higher education institutions in 2017, Bas-Uele 4 2 0 6 almost evenly split between the public and private sector Equateur 5 3 2 10 (Table 13). Private institutions are mostly concentrated Haut-Katanga 2 3 9 14 in North Kivu, Kwilu, and Kasai Central. Between 2013 Haut-Lomami 3 6 0 9 and 2017, 25 new higher education institutions opened, Haut-Uele 8 3 1 12 including eight in the private sector. As with secondary- Ituri 6 11 0 17 level institutions, this growth has caused difficulties Kasai 5 10 10 25 Kasai Central 2 13 6 21 Kasai Oriental 4 2 6 12 Higher education institutions for technical Table 13.  Kinshasa 6 2 38 46 medicine by ownership and province Kongo Central 8 21 20 49 Ownership Kwango 8 5 6 19 Province Public Other Private Total Kwilu 8 12 13 33 Bas-Uele 0 2 2 Lomami 4 6 4 14 Equateur 2 2 Lualaba 2 3 5 10 Haut-Katanga 2 2 4 Mai-Ndombe 9 2 1 12 Haut-Lomami 0 2 2 Maniema 4 2 0 6 Haut-Uele 2 1 3 Mongala 4 7 4 15 Ituri 1 2 3 North Kivu 8 16 3 27 Kasai 4 4 North Ubangi 2 2 4 8 Kasai Central 7 5 12 Sankuru 5 6 0 11 Kasai Oriental 1 1 2 South Kivu 15 12 23 50 Kinshasa 1 10 11 South Ubangi 4 4 5 13 Kongo Central 6 4 10 Tanganyika 4 3 1 8 Kwango 4 1 5 Tshopo 12 4 5 21 Kwilu 6 6 12 Tshuapa 3 4 2 9 Lomami 3 2 5 Total 145 164 168 477 Lualaba 0 2 2 Source: MSP 2017i. Mai-Ndombe 1 2 3 Maniema 4 1 5 health workers trained. For this reason, comprehensive Mongala 2 2 data are not available about the number of health work- North Kivu 8 7 15 ers trained in the private—or even the public—sectors. North Ubangi 2 2 Sankuru 1 3 4 South Kivu 7 2 9 Higher education institutions for technical medicine South Ubangi 2 2 Higher education institutions for technical medicine are Tanganyika 1 1 2 public and private higher education training institutions Tshopo 3 3 and universities whose mission is to train specialized managers in the fields of science, medical, and paramedi- Tshuapa 2 2 cal techniques while researching how to adapt new tech- Total 72 56 128 niques and technologies to the DRC context. Training Source: MSP 2017i. HEALTH WO R KFO R C E 67 in compiling information on their performance, and no DRC, three public and two private, located in the prov- training numbers are available (MSP 2017i). inces of Haut-Katanga, Kinshasa, North Kivu, and South Kivu (MSP 2017i) Universities with faculties of medicine and pharmacy Based on the 2017 National Directory of HRH, there are 7.2.2  Quality of training 107 faculties of medicine and pharmacy, of which 30 are There are several organizations involved in the accredita- public and 77 are private (Table 14). Of these, Kinshasa, tion of training institutions, some with overlapping man- North Kivu, and South Kivu have the most faculties, with dates. Stakeholders interviewed highlighted that these 12, 19, and 16, respectively. There are 102 faculties of overlaps create problems for the accreditation system. medicine and only five faculties of pharmacy across the For example, some stakeholders had heard of municipal- ities accrediting training institutions that did not meet Universities with faculties of Table 14.  the necessary standards. The multiplicity of stakeholders medicine and pharmacy and the rapidly growing number of private training insti- by ownership and province. tutions has complicated compliance. If the MSP identi- fies a training institution that does not respect training Ownership Province prerogatives, it can recommend closure, but it cannot Public FBO Other Private Total enforce that recommendation. Stakeholders stated that Bas-Uele 0 1 0 1 often authorities from the Ministry of Commerce and Equateur 1 0 1 2 municipalities ignore the MSP’s recommendations and Haut-Katanga 3 1 4 8 do not close training institutions because of political Haut-Lomami 1 1 2 4 concerns, as well as misunderstandings about roles and Haut-Uele 1 0 0 1 competencies in the accreditation process. In addition, Ituri 1 1 1 3 the lack of a federation or association of private training Kasai 1 0 2 3 Kasai Central 2 1 2 5 Kasai Oriental 1 1 1 3 Kinshasa 2 4 6 12 Kongo Central 1 0 2 3 Kwango 0 0 0 0 Kwilu 2 0 1 3 Lomami 2 0 1 3 Lualaba 1 0 0 1 Mai-Ndombe 1 0 0 1 Maniema 1 1 2 4 Mongala 0 0 1 1 North Kivu 2 5 12 19 North Ubangi 1 0 0 1 Sankuru 2 1 0 3 South Kivu 2 3 11 16 South Ubangi 0 1 0 1 Tanganyika 1 0 3 4 Tshopo 1 0 4 5 Tshuapa 0 0 0 0 Total 30 21 56 107 Source: MSP 2017i. Centre de santé Medicare 68 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O institutions makes it more difficult for the MSP to formally well as public schools are motivated to acquire, train, and integrate them into the Human Resource Information graduate students, even if they do not have the necessary Solution (iHRIS). skills to practice, because most of the institutions’ operat- Although the MSP would like to play a larger role in enforc- ing budgets come from the schooling of students. ing its recommendations, it lacks the means to do so, as Both the Orders and the ASPS expressed interest in sup- highlighted by the case of Haut-Katanga. The MSP cur- porting the MSP to improve the quality of HRH training. rently has 35 inspectors to cover the former province of The Orders especially would like to play a larger role in Katanga, which includes Haut-Katanga’s 25 training insti- accreditation, supervision, and compliance processes tutions of various levels and health professionals (MSP for both training institutions and providers but lack the 2017j). These inspectors also still cover the entirety of the authority and human resources to do so. former Katanga province, bringing their total responsibil- ity to 43 training institutes and an associated 11,312 health Continuing education professionals (ONRHS-RDC 2015). This added burden Quality of care is a serious concern to the MSP, and it has dilutes their ability to follow up and enforce MSP deci- set up a Directorate of Continuing Education in response. sions (MSP 2017j). To increase efficiencies, the MSP has organized thematic trainings within the framework of specific programs. To Quality of training programs roll these out nationwide, the Directorate plans to hold a Although training institutions are supposed to be at dif- training-of-trainers event and send trainers to the prov- ferent technical levels, stakeholders could not confirm inces to create provincial training mentors. However, the there were significant differences in the content of train- Directorate is underfunded and has only successfully ing programs (for example, training models, syllabi, and rolled out these reforms in four of the 26 provinces (MSP curricula) delivered by secondary and higher-level train- 2017j). Beyond this internal organization, the MSP uses ing institutions or universities. Most of the private training higher education institutions and universities to train institutions also lack infrastructure, equipment, qualified clinical specialists and conducts on-the-job training at teachers, and sites suitable for practical training. the School of Public Health in Kinshasa and Lubumbashi One-fifth of the medical schools created between 1998 (MSP 2017j). Anecdotally, these continuing education and  2008 did not meet the required standards set by efforts are open to private providers, but little data are regional bodies to deliver diplomas to graduates. For available about their uptake. example, Conseil Africain et Malgache pour l’Enseignement Supérieur cites a lack of senior lecturers in private training 7.3  HRH IN THE PRIVATE SECTOR institutes as a serious concern. Despite that, these institu- 7.3.1  Data on HRH in the private sector tions continued to produce more than 2,000 new physi- cians each year and more than 4,000 new nurses, albeit Data regarding HRH numbers in the private sector are dif- without formal diplomas, leading to a health workforce of ficult to obtain. Most of the HRH data in the DRC come varying quality (Durham et al. 2015). The Orders were from the public sector. However, the MSP is progressively quick to note the impact on service delivery. For example, involving the private sector in more HRH data activities. the Order of Pharmacists in Kolwezi informed the team For example, the private sector was invited to partici- that they had received several complaints regarding train- pate in training sessions on different HRH management ing institutions, in particular the lack of laboratory equip- modules when the Observatory for HRH was established. ment that led to students graduating with incomplete These efforts have had some success—the Monkolé Health training. The poor quality of training in certain schools Center, which is a training and research institute with its has also led some Orders to refuse to register graduates own hospital, shares its data with the MSP’s Directorate and grant them licenses. of Human Resources and is a member of the Observatory for HRH (MSP 2017j). Despite challenges with the quality of their programs, training institutions continue to provide certificates to Data on HRH in the private sector also remain limited their students. Stakeholders highlighted that private as because of a lack of reporting. The 2015 Country Profile HEALTH WO R KFO R C E 69 indicated that most health providers worked in the pub- lic sector, with only 7 percent of the total HRH working Box 33.  The limits of contracting for HRH in other sectors, including the private sector, parastatals, the army, and the police (Table 15). Other sources present Though contracting can improve the distribution of HRH, conflicting data, which seem to indicate higher HRH num- non-compliance has led to some dissatisfaction with this bers in the private sector. A 2015 study indicated about practice. Several stakeholders stated that the MSP did 11,000 physicians were registered nationwide, with fewer not consistently pay salaries in a timely manner, which than half (∼5,000) working in the public sector, signifi- impacted on the ability of facilities to operate as they used funds to pay for salaries rather than other costs cantly more than the numbers in Table 15 (Durham et al. or investments. Others stated that there were issues 2015). The numbers registered with the Order of Pharma- with transparency, traceability, and accountability, with cists are also significantly higher than the 303 pharmacists providers not implementing recommendations following reported in Table 15. The Order of Pharmacists stated they audit missions. had 2,000 registered pharmacists in 2017, of whom 1,300 practice (7sur7.cd 2017; Order of Pharmacists 2017). Contracting between the public sector and FBOs also makes it difficult to obtain clear data about HRH num- the two parties (Barroy et al. 2014). Likewise, delays in bers in the private sector (see Box 33). For example, an registration affect data on HRH. The Order of Doctors in estimated 65 percent of staff working in health facilities Katanga indicated that there were 1,300 public and pri- supported by the Catholic Church are also registered vate doctors in 2017, 871 of whom were registered with as health personnel with the MSP, and 30 percent are the Order. Ninety-four percent of doctors are general- on MSP payroll registers through agreements between ists, and 70 percent are based in Lubumbashi (Order of Doctors 2017). The significant difference between the number of doctors in the province and the number reg- Human resources for health by category Table 15.  istered with the Order is caused by a month-long delay and by sector in the DRC, 2015 between when new doctors graduate and when they receive final degrees, thereby allowing them to register to Public Other become a member of the Order. For doctors waiting for Categories Sector Sectors* Total registration, the Order has established a six-month tutor- Doctors 6,246 1,259 7,505 ing system that is renewable once (Order of Doctors 2017). Dental surgeons 51 19 70 Administrators 2,366 53 2,419 Although accurate data on the numbers of private sec- Pharmacists 288 15 303 tor providers are difficult to obtain, the 2014 WHO SARA Nurses 60,332 3,350 63,682 report found that trained health staff and health proto- Midwives 1,555 282 1 837 cols were slightly more available in the private sector in Physical therapists 302 62 364 most health areas, except for malaria (Figure 36). Laboratory technicians 2,160 155 2,315 The geographic distribution of health workers shows Radiology technicians 287 20 307 large disparities between Kinshasa and the rest of the Nutritionists 586 19 605 country, especially for physicians. Kinshasa had 1.3 physi- License in physical medicine 0 7 7 cians per 10,000 inhabitants in 2013, whereas most other Pharmacy assistants 212 12 224 provinces had half that ratio. For nurses, the former prov- Sanitation technicians 207 18 225 ince of Bandundu and Equateur seemed better off than Dentist (odonatologist) 2 2 4 Kinshasa, with over 13,000 nurses each compared with Other health professionals 5,339 756 6,095 Kinshasa’s fewer than 4,000 (World Bank 2014). Available Total 79,933 5,797 85,730 data from reports and stakeholders indicate that across the public and private sectors, there is a disproportion- * The Other Sectors category includes private, parastatal, denominational, army, and police. ately high percentage of practicing nurses and a shortage Source: ONRHS–RDC 2015. of physicians. National norms per 10,000 inhabitants for 70 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Figure 36.  Availability of trained HRH and protocols by type of service and sector 100% 87% 82% 80% Providers trained on protocols 74% 63% 62% 58% 58% 60% Public 53% 54% 47% 46% Private 36% 40% 17% 19% 20% 0% DS ic y ic e es l ia is ra rv iv rv nc os ar ic vi es es se rat AI se rge al rv ul ro V/ M rc th u se et ric e al d c HI be et m tir th st e e he an Tu An al he ob plet ild ve ch tati nt m ce Co en es ev ol Pr Ad Source: MSP 2014a. health center staffing are seven health workers (five nurses sector are irregular, and the pension system has not been and two nonprofessional staff). In practice, many urban functioning for a long time. As a result, dual practice has health centers have more than 30 nurses for about five expanded, despite its illegality. A study by the Observa- outpatient clients per day (Ntembwa and van Lerberghe tory for HRH found that almost half of all public-sector 2015). In addition to the shortage of physicians, the DRC health workers engaged in additional, nonclinical activ- has a lack of pharmacists and midwives. In Kinshasa, ities to supplement their income, whereas fewer than for example, there is one qualified pharmacist for every 10 percent conducted clinical work in the private sector 42,662 inhabitants (Office Fédéral des Migrations 2014). (ONRHS-RDC, 2015). Of the public-sector health work- A census completed by the UNFPA found there were only ers conducting dual practice, many do so from home or 4,200 midwives for the entire country (UNFPA 2014). in a private clinic (Figure 37). Health workers are likely An analysis of the labor pool suggests that the number of to earn more working in the private sector, making dual HRH working in the private sector has grown significantly practice financially attractive (Bertone and Lurton 2015). in recent years as well. This may be attributable to the 10-year hiring freeze on civil servants and the growing 7.4 RECOMMENDATIONS number of private facilities. In addition, the private sector Improve coordination between stakeholders involved offers opportunities for both generalists and specialists, in HRH management with some specialties available only in the private sector Finding: The accreditation process for training insti- (for example, physiotherapy). tutions, the limited resources in training schools in the public sector, and training schools in the private sector 7.3.2  Dual practice that do not meet quality standards have led to significant Although dual practice is not legally authorized, it is variations in the quality of HRH produced. There is an commonplace in the DRC. Wage payments in the public urgent need to clean up the training system, especially HEALTH WO R KFO R C E 71 Location of private practice among surveyed public health workers who conduct Figure 37.  dual practice, 2015 80 64 60 Frequency 48 40 31 26 20 8 5 5 0 Home Private Other Patient's NGO Rented Other's clinic home space house Source: ONRHS-RDC 2015. in the private sector, and establish and strengthen the provincial, and local levels. Donors, the government, the framework and accreditation process for training institu- Orders, and other partners should then assist the training tions for health personnel. institutions to upgrade the quality of their programs to meet the newly defined accreditation standards. Recommendation: Support the new Directorate of Human Resources at the MSP in collaboration with the Ministry of Education (Ministère de l’Enseignement Primaire, Build public–private links to facilitate Secondaire et Professionnel) and the Ministry of Higher practical training Education (Ministère de l’Enseignement Supérieur et Finding: To ensure the quality of health services in the Universitaire) to institute a coordinating body to facili- DRC, it is critical that health sciences students such as tate the regulation and standardization of training pro- doctors, nurses, and midwives receive sufficient practical grams to improve the quality of HRH. The coordinating hands-on training as part of their preservice academics. body should begin by improving the quality and stan- Assessment informants indicated some students are dardization of training by making an inventory of edu- entering post-graduation clinical care without sufficient cational institutions (materials, infrastructure, staff, level practical training. This negatively affects the quality of of recruitment); revising and aligning training curricula care. Historically, students studying at private medical (models and syllabi); and prioritizing training needs based training institutes (PMTIs) have had to rely on securing on the availability of HRH and epidemiological needs. practicum opportunities within public health facilities, Stakeholders involved in the management of HRH, such but these are limited. PMTIs and private students have as associations (for example, ASPS) and orders, should contended with unclear private-to-public student place- be an integral part of training program development, ment procedures, fluctuating costs for placements, and including the design of curricula and implementation of payments demanded from hospital administrations. the accreditation system. Recommendation: To address the lack of practical train- ing, public and private stakeholders should clarify and Establish and enforce the accreditation system codify standard operating procedures related to place- for training institutions ment of private students (all cadres and disciplines) in public facilities. As alternatives to public practicum sites, Finding: The accreditation process for training institutions private-to-private practicum approaches have been offered is unclear because of the multiplicity of actors involved to PMTI students, but these are even more limited than (that is, the MSP, Ministry of Commerce, and municipalities). public ones. It is important to work with a broad range Recommendation: Develop in collaboration with rele- of PMTIs and private provider networks to design and vant stakeholders a formal structure for the accreditation onstrate a private sector preferred practicum model dem­ system and define regulations, roles, responsibilities, and (featuring private-to-private student placement as an authorities of the different stakeholders at the national, alternative to public practicum sites). The goal is to design 72 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O a preferred model for private-to-private student place- Recommendation: Undertake a mapping with the MSP’s ment, including the identification of a student cohort with Directorate of Human Resources, stakeholders from the PMTI student rotation through practice areas, including public and private sector, and the National HRH Obser- reproductive and child health clinics, labor and delivery, vatory, of the available HRH in the private sector for key and general medical practice. health areas to identify and address HRH gaps. Increase the quality and accessibility of training Incorporate the private for-profit sector Finding: Training plans exist for all HRH levels, but the in the MSP’s HRH staffing planning quality and accessibility of trainings varies because Finding: Private providers say that NGOs (including of a lack of resources, a lack of quality trainers, and FBOs) are favored by the MSP above for-profit health geographic/financial constraints. The Yaoundé training facilities for HRH staffing. centers in Cameroon and Dakar, with the support of Recommendation: Explore in collaboration with the MSP Japan International Cooperation Agency (JICA) and the and ASPS opportunities to integrate the private for-profit National School of Health and Social Development, are in HRH staffing plans, including opportunities to estab- being transformed into a regional center for nurses and lish contracting mechanisms in exchange for tax relief, as midwives of French-speaking countries. is done with the nonprofit sector. Recommendations: yy Support the MSP with partners to set up training insti- Implement a systematic approach tutions for trainers modeled on the Yaoundé training to increase HRH motivation centers. Finding: Initiatives to increase HRH motivation are lim- yy Support the MSP to work with partners and develop ited by the MSP’s inability to pay the salaries of its staff and implement an integrated strategy to improve in public facilities and private facilities they are contract- the quality and accessibility of trainings; this could ing with. This creates an incentive for dual practice, with include facilitating financing for equipment and infra- some providers recommending clients at their public structure, developing a scholarship scheme to enable facilities to visit their private facilities for treatment to providers to acquire relevant complementary skills increase revenue. One option to explore is use PBF, being in targeted health zones, sponsoring health area- careful not to accidentally create incentives for providers specific training courses, or developing an e-Learning to work in one health zone rather than another, as has platform accessible to the public and private sector. happened previously with PBF programs. Recommendation: Develop and implement with the Identify and address HRH gaps in collaboration MSP’s Directorate of Human Resources a systematic with partners approach to improve HRH motivation in both the pub- Finding: Data on HRH in the private sector are limited lic and private sector in collaboration with partners, tak- because not all stakeholders report to the MSP. Based on ing into account internal initiatives, such as the ongoing available data, HRH availability, especially specialists such reform of the pension system in collaboration with the as laboratory technicians, varies significantly between World Bank, as well as external mechanisms such as PBF urban and rural areas, as well as between provinces. programs. HEALTH WO R KFO R C E 73 8.  Health Information Systems The DRC continues to struggle with underdeveloped and scale up of the national health information system, infrastructure. For example, only 16 percent of the popula- Système National d’Information Sanitaire (SNIS), and other tion has access to electricity, despite hydroelectric dams digital health initiatives. However, significant progress has in the DRC that have the potential to generate enough been made, and strong private sector participation has power for most of the continent (Lightening Africa 2017). bolstered efforts, holding promise for future advances. The lack of basic power poses significant challenges for industries, such as telecommunications, which are a build- 8.1.1 DHIS2 ing block for development. DHIS2 is the preferred open source, electronic health The telecommunications sector is loosely regulated, and management information system in 60 countries, includ- the national operator Société Congolaise des Postes et des ing the DRC. DHIS2 is currently used as the SNIS platform Télécommunications provides minimal services (Budde. for data management and analysis, health program moni- com 2017). Six mobile network operators (Vodacom, toring and evaluation, facility registries, service availability Orange, Airtel, Africell, Supercell, and Tatem Telecom) are mapping, and some logistics and supply chain manage- the principal providers of telecom services in the DRC, ment. The budget for the SNIS Strategy for 2018–20 is demonstrating strong private sector participation. Despite US$30.5 million, some of which could be used to bolster a market with multiple competitive international service digital implementation, improve private sector participa- providers, the mobile SIM penetration (unique subscribers) tion, or match private sector investments. is only 26 percent of the population, making the DRC one of the most poorly connected countries in the region At the end of 2017, there were 17,859 facilities registered (GSMA 2017). This low penetration is attributable to per- in DHIS2 across the DRC. Facilities in DHIS2 are catego- sistent social and political instability, security threats, and rized as public, FBO, or private. Of all facilities registered a high poverty rate. in DHIS2, 20 percent (3,501) are categorized as private, 10 percent (1,872) as FBO, and 53 percent (9,493) as The DRC’s Internet and broadband market has been public. Seventeen percent (2,993) are not defined in any slow to grow. In 2013, the DRC was connected to low- category. This means that 30 percent (5,373) of all regis- cost, high-quality international bandwidth through a sub- tered facilities across DRC are in the private sector (FBO marine fiber-optic cable. The national operator is rolling and private). Over half (53 percent or 2,848) of these out a fiber-optic national backbone network with sup- are private health centers, 26 percent (1,414) are private port from China (Budde.com 2017). Despite this progress, health posts, and 14 percent (771) are private hospitals. international bandwidth is extremely limited, with mobile broadband available to only 7 percent of the population Implementing a health management information system (GSMA 2015). However, mobile operators are keen to at scale is complex, requiring close collaboration between grow mobile data services and capitalize on smartphone private and public actors, as well as updates to policies, procedures, and tools. In collaboration with many part- usage and capabilities. ners, the MSP rolled out DHIS2 across all 516 health zones in 2016. The zones have moved from paper-based report- NATIONAL HEALTH INFORMATION SYSTEM 8.1  ing at all levels to electronic reporting at the health zone AND THE PRIVATE SECTOR level (IMA World Health n.d.). Integrated and modu- The lack of telecommunications and power infrastructure lar approaches across health programs are used in the has posed significant challenges to digital implementation revised paper data collection tools. These documents are 74 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O then brought to the health area for a monthly preliminary Private and FBO facilities that are registered in the health validation event, which gives each facility the opportu- system have slightly better reporting rates than do pub- nity to report and discuss key indicators. The paper- lic facilities (Figure 38). There is substantial variation in based documents then move up the Central Bureau reporting rates by province but less across facility type of the health zone, where they are further validated at within the province. Three-quarters (75.1 percent) of pri- the monitoring meeting (réunion de monitorage) and vate facilities registered nationally submitted a report in entered electronically into DHIS2 by Central Bureau staff. November 2017 on their basic services, compared with The rollout has resulted in more than 89 percent of the 74.7 percent of registered FBOs and 71.1 percent of public country using the new platform (MSP 2017j). facilities. Across all of the DRC, Kinshasa has the worst Across the provinces examined in this assessment, there reporting rates for all facility types. One limitation of are differences in private sector participation (Table 16). In DHIS2 data is there is no indicator for the quality or com- Kasai Oriental, Kinshasa, and Haut-Katanga, private pro- pleteness of reporting (although there is an indicator for viders participate in large numbers (70 percent, 68 per- timeliness). The reporting indicators provided are binary cent, and 60 percent, respectively) of registered facilities. (did or did not report); knowing whether the quality of This is likely due to greater urbanization in these three the data is worse in the public or private sector would be provinces. There are few registered private sector facili- useful in targeting technical assistance. ties in Tshopo, and there are too many undefined facilities The high private sector reporting levels in DHIS2 were in North Kivu to describe private sector participation. reflected in interviews with private providers across prov- One of the biggest achievements of the DHIS2 transi- inces. Although several challenges were mentioned, all tion is registry of private sector facilities as part of the private providers interviewed were adamant about their public health reporting system. Like public facilities, adherence to their monthly reporting commitment (qual- private facilities that register receive training on the ity of reporting was not discussed). Among private pro- new, streamlined, paper-based data collection tools, viders, there seemed to be a clear understanding of the and receive many of the same free products (for exam- necessity of reporting and attendance at the monthly val- ple, vaccines and malaria medications) for public distribu- idation events. Although transport and per diem costs of tion. In return, registered private facilities summarize key the monthly reporting event were mentioned as a finan- health indicators monthly and participate in public health cial inconvenience, private providers seemed resigned to service delivery (for example, administration of vaccines covering these costs for the near future. They were more on monthly vaccine days). vocal about the need for the Central Bureau to more Number and type of facilities registered in DHIS2 Table 16.  in selected provinces, 2017 Percent (%) of DHIS2 Private Sector Facilities that Are Province Other Private* FBO State Not Defined Total Private Sector Kasai Oriental 360 46 127 45 578 70 Kinshasa 567 76 100 204 947 68 Haut-Katanga 556 72 283 138 1,049 60 Kongo Central 499 204 677 63 1,443 49 South Kivu 126 340 459 81 1,006 46 Lualaba 123 79 166 70 438 46 Tshopo 68 44 477 99 688 16 North Kivu 0 0 316 699 1,015 0 *Includes NGO, for-profit, and nonprofit. Source: MSP 2018. HEALTH I NFOR MATI O N SYST E M S 75 Figure 38.  Reporting rate for November 2017, by facility type 100% 99% 96% 97% 94% 95% 92% 89% 89% 85% 84% 83% 85% 75% 72% 80% 65% 65% 60% 55% 48% 42% 40% 35% 23% 26% 20% 0% 0% 0% Public FBO Other Private Public FBO Other Private Public FBO Other Private Public FBO Other Private Public FBO Other Private Public FBO Other Private Public FBO Other Private Public FBO Other Private Haut Katanga Kasai Oriental Kinshasa Kongo Lualaba Nord Kivu Sud Kivu Tshopo Central Source: MSP 2018. consistently provide paper-based reporting tools, which are not used for decision making. Finally, updates to the they photocopied themselves regularly. facility registry purportedly are made only once per year, which potentially creates a large data lag. Implementation challenges Another challenge that both private providers and imple- menting partners highlighted was the lack of feedback As with all new health information systems, challenges offered to private providers. Presumably issues that are remain, particularly with regard to private sector inclu- sion. First, it is not apparent what percentage of private facilities in the DRC is registered in DHIS2. This makes it difficult to know whether the registered private facilities are representative of the whole private sector. National standards on physical infrastructure, equipment, and ser- vice provision required for registration can be difficult to meet for smaller, poorer facilities in the private sector. This means that these facilities are not able to formally regis- ter and are therefore not included in the facility registry, despite continuing to provide important health services to low-income, rural, and/or vulnerable populations. Sec- ond, of the private facilities that are registered in DHIS2, nearly 3,000 (17 percent) are not categorized as public, private, or FBO, and therefore it is difficult to assess dif- ferences in public versus private participation and health indicators. Third, there are no recurring reports that are generated to offer insight into differences in public and private service delivery. Collecting more-nuanced data will not be helpful if indicators are not tracked and data Kalebu Espoir 76 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O identified in public facilities through routine reporting are For example, none of the CDRs are aware of the items and corrected through action by the MSP in its role as steward quantities ordered from implementing partners (SIAPS of public health facilities. However, private facilities do et al. 2014). In a 2014 study of the DRC LMIS, health not receive any kind of feedback or report on how they facilities in the public and private sector reported that are performing relative to other facilities or over time. It they spend up to four days a month preparing reports may be that public facilities are not receiving this kind of (SIAPS et al. 2014). Electricity is unreliable or not avail- feedback either. IMA World Health is working on simple able, which means manual forms are used to capture autogenerated dashboards that can be shared with facil- data; poor data availability and accuracy are therefore ities; this could address the concern that the current flow serious concerns. data for decision making is one directional. Although DHIS2 has the capacity to aggregate health DHIS2 data entry and transmission currently occur at the service data and aggregate public health indicators, health zone level, and therefore Internet and mobile data it may not be sufficiently adept at managing complex, connectivity is not a pressing issue for private providers. subnational inventory, ordering, quality assurance, fleet However, the SNIS Division and provincial leadership both management, distribution, pharmacovigilance, and other repeatedly cited the challenge of connectivity for trans- logistics tasks that are needed to support a well-functioning mitting data. The tardiness or complete absence of data LMIS. Therefore, many countries are moving toward the can significantly delay decision making and is particularly use of a separate yet interoperable platform for stock problematic in rapidly evolving epidemics. MEASURE Eval- management, such as OpenLMIS. An interoperable LMIS uation is exploring the possibility of decentralizing data platform can easily transfer information to other sys- entry and transmission to the health facility level, which tems without complex data restructuring or recoding. means that a more-expansive connectivity solution will An electronic LMIS automates redundant hard copy likely be needed in the next five years. One solution IMA processes and can feed stock levels and inventory data World Health is currently exploring is the reprogramming into the DHIS2, where it can be compared against cov- of data packets so that they are smaller in size and easier erage information. to transmit. A PPP between mobile network operators, An improved pharmaceutical information management implementing partners, and the MSP may help address system could also address other challenges, such as the complex challenge of data connectivity. clustering of private pharmacies in areas with sufficient A final limitation of the current DHIS2 system in the DRC population, which leads to a dearth of clients in one geo- is that it does not collect information on pharmacies, graphic area with underserved populations elsewhere. supply chain, stock, HRH, or medical records. This is a These inefficiencies could be identified by strong private limitation both because pharmacies constitute a major sector participation in a new electronic LMIS. component of the private sector and because these data UNFPA in the DRC is a strong proponent of establishing are critical to managing the health workforce, distributing an interoperable electronic LMIS. There are several ongo- products efficiently, and understanding population health ing attempts to initiate an electronic LMIS through the longitudinally. Although DHIS2 does have the potential to piloting of the UNFPA Channel software in 14 health zones support these types of data collection, other platforms from 2011 to 2014 and the DHIS2 drug module that was that are specifically developed for logistics management, piloted in 40 health zones in Kinshasa, Kongo Central, and HRH management, and medical record management may Kisangani more recently (UNFPA 2017b). However, none offer more-nuanced insights for decision making. of these initiatives has yet been evaluated. UNFPA is in the process of evaluating the VillageReach implementation of OpenLMIS, and that evaluation should be available in 8.2  OTHER INFORMATION SYSTEMS 2018. UNFPA plans to leverage these results to develop an 8.2.1  Logistics management and information system operational plan for an electronic LMIS. The current (June Reliable data about health products are a weak link in the 2017) road map for an LMIS would benefit from lessons SNIS (Office Fédéral des Migrations 2014). There are sig- learned on how to incentivize and engage with the private nificant challenges in the current data flow because of the sector during this process, particularly as such a substan- complexities of the supply chain, as described in Section 5. tial proportion of health products and other drugs flow HEALTH I NFOR MATI O N SYST E M S 77 Box 34:  mHero mHero is a mobile phone-based communication system that uses basic text messaging to connect ministries of health and health workers without the need for a smart- phone or tablet. mHero was the “hero” of the Ebola crisis in Liberia in 2014, where it was used to collect and com- municate critical epidemiological information between the health information system and health workers. Devel- oped by IntraHealth and UNICEF, mHero can also support ongoing health communication and is useful for bringing together existing components of a country’s health infor- mation system, such as DHIS2 and iHRIS, using interna- tional interoperability standards. Although not currently Lab at Clinique IK, Kinshasa used in the DRC, mHero is a communication system that could build on data from iHRIS and DHIS2, particularly in the context of the private sector, where two-way commu- through the private sector, NGO networks or social mar- nication between private providers and Central Bureaus keting organizations, or private wholesalers, drug shops, is more limited. and pharmacies. 8.2.2  Health workforce information systems board for health program decision making. This system will In 2014, IMA World Health and IntraHealth began piloting use advanced visualization and organization techniques an electronic, open source iHRIS in Kasai Province. iHRIS to provide actionable timely data from central, provincial, helps health systems in low-resource settings collect and health zone, facility, and community levels, while keeping manage data on HRH numbers, skills, qualifications, loca- its commitment to avoid parallel systems and not dupli- tions, and other important factors for decision making. cate effort. Although IHP is largely focused on the public These data can help countries address HRH shortages sector, it would be useful to explore how to integrate the and other barriers across the health sector (see Box 34 private sector at the conception of this dashboard so that for example of interoperability with mobile platforms). it is useful and applicable to the total health system. As one early example of the pilot’s success, it led to the identification and removal of 2,000 ghost workers who 8.3 DIGITAL AND TELECOMMUNICATIONS were drawing a salary without actually working. iHRIS OVERVIEW currently includes FBO providers but does not yet have 8.3.1  Mobile network operators strong engagement with private for-profit and nonprofit The top four mobile network operators (MNOs) by mar- providers. Private facilities that are registered in DHIS2 ket share in the DRC are Vodacom, Orange, Airtel, and could have their staff registered in iHRIS as well, and this Africell (Table 17). Each offers a mobile money service could facilitate contracting between the public-sector in addition to standard voice and data services. All are and private providers and facilities. Although they are not interested in expanding brand awareness, market share, yet integrated, iHRIS is interoperable with DHIS2, and the and geographic presence and can offer discounted or two systems can complement each other in useful ways. bundled data, voice, and other media and communi- cations services. MNOs have had varying experiences 8.2.3  Integrated Health Project data dashboard collaborating with government partners but are all will- In 2018, the USAID Integrated Health Project (IHP) was ing to explore digital health partnerships and address awarded in the DRC, which proposes to build on existing MSP and health implementer needs. The geographic national and subnational systems to offer a data dash- areas of particular commercial interest to MNOs inter- 78 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Table 17.  Mobile Network Operator (MNO) User Base and Market Share Mobile Money Name MNO Name Mobile Subscribers Market Share (%) (Number of Subscribers) Vodacom 13 million ∼38 M-Pesa (2.5 million) Orange 9.5 million ∼30 Orange Money (1.2 million) w 8 million ∼24 Airtel Money (1 million) Africell 3.5 million ∼11 Africell Money (N/A) Source: Based on MNO self-report in interviews. viewed include Kinshasa, Kongo Central, Haut-Katanga, 2017, Orange reported approximately 9.5 million active and North Kivu because of their relatively dense popula- users and a 30 percent mobile subscription market share. tions and economic activity. Orange Money, the mobile money branch of Orange, reports 1.2 million subscribers, which constitutes a quar- ter of the mobile money market. As one of its competitive Vodacom advantages, Orange points to a strong regional presence Vodacom Congo, established in 2002, in francophone West Africa that offers resources other is the national subsidiary of Vodafone operators cannot access. Bolstered by the acquisition of International. Vodacom has the larg- Tigo, Orange has a fairly strong presence in many prov- est share of the mobile market, with inces but a weak presence in the central region of the 13 million subscribers. M-Pesa is the DRC (for example, Bandundu and Twshwapa). Orange Vodacom mobile money service in the plans to invest more heavily in infrastructure in rural DRC, which offers financial services, including savings areas, an interest that would converge with the MSP’s and loans programs. Vodacom is in the process of estab- desire to improve connectivity for rural health areas and lishing a local, cloud-based platform called Mezzanine zones. Orange has also worked on a number of develop- that can support a wide array of data collection, commu- ment projects, including a malaria project with Soins de nication, and other digital services. Among other appli- Santé Primaires en milieu Rural (SANRU) and a mobile cations, Mezzanine has a stock visibility solution that data collection education project (Orange 2017). tracks the availability of vaccines in Mozambique, malaria medicine in Tanzania, and medicine for extreme drug- Airtel resistant TB in South Africa. The Mezzanine platform has also supported projects focused on community care Airtel has eight million active users management, patient management, and workforce man- and estimates that it has 24 percent agement in sub-Saharan Africa. Vodacom plans to start of the mobile market. Airtel currently building Mezzanine in the DRC in April 2018 and expects focuses its client development efforts to have it completed in October 2018. Vodacom is actively on enterprises and NGOs, where the looking for potential clients who are interested in such ser- company says there is stronger pre- vices and already has ongoing partnerships and contracts dictability and stability compared with government clients. In addition, Airtel is trying to with the MSP and implementing partners, such as Manage- distinguish itself as “The Smartphones Network,” and its ment Services for Health (MSH) (Vodacom 2017). business strategy is focused more on data, broadband, and Internet access. Airtel was the first operator to estab- Orange lish a mobile money branch in the DRC in 2013. By the end Orange established itself in the of 2017, Airtel reported approximately one million mobile DRC in 2012, when it purchased money users, of which approximately 700,000 were CCT, a Chinese telecom, and then active. By Airtel’s accounting, the company has the most further expanded its presence with cash-in–cash-out locations in the nation. Geographically, the purchase of Tigo in 2016. By Airtel noted that the company has a particularly strong HEALTH I NFOR MATI O N SYST E M S 79 usership and presence in the east, Katanga, and Kinshasa, and a moderate presence in Kongo Central, Matadi, and Kivu/Goma. Airtel’s investments in data infrastructure have been slowed by political instability. Airtel also has some development partnerships but does not seem to have a strong corporate social responsibility or founda- five hospitals in Kinshasa and Lubumbashi, WapiMed tion presence in the DRC (Airtel 2017). helps people seeking medical treatment locate public or private facilities, providers, and pharmacies in their Africell geographic area and secure appointments and consul- tations. All appointments are currently made by phone, Africell DRC was established at the so providers do not even need to have a smartphone end of 2012, but they did not receive or the Internet, but more digitization is planned so that authorization as a telecom until 2014. appointments can be made online. It is therefore a relative newcomer to the DRC, with operations in Uganda, WapiMed’s approach to identifying and adding facilities the Gambia, and Sierra Leone, mak- has been to work with the Order of Doctors and map net- ing it much smaller and more locally works of referral hospitals and health centers. Often the focused than the other three large international oper- Order does not have location data for its member phy- ators. Marketed as “The People’s Network” (le réseau sicians, so this partnership is benefiting both the Order du peuple), Africell advertises low-cost data and voice and WapiMed. WapiMed would benefit from further part- services, allowing the company to reach lower-income nership with the MSP, which has more-extensive lists of market segments. Africell has approximately 3.5 million public and private facilities. subscriptions and is looking to grow its market share. The intended business model of WapiMed is for health Africell Money, launched in 2017, offers classic mobile providers and facilities to subscribe to the service. Cur- money services. Geographically, Africell operates mostly rently, joining and using the app is free while a client in the Kinshasa and Haut Katanga geographic areas, with base is developed. Ultimately, WapiMed wants to limit some additional services in Kongo Central. Although there participation to facilities that have a certain level of is not a foundation or corporate social responsibility divi- quality, but right now they do not have clear quality sion at Africell, the company has supported a number of criteria and admit that facility acceptance is currently development projects, including for HIV, gender-based subjective. violence, education, and Ebola (working with the WHO in In addition to geolocation and appointment services, Sierra Leone). Africell’s support is often channeled through WapiMed is interested in developing a mobile wallet its production house, which supports broadcasts, events, for health that can facilitate the US$12–US$15 million in and other communication through television, radio, and remittances that are sent by the diaspora annually to other telecommunications channels (Africell 2017). pay for health services of friends and family in the DRC. WapiMed is also expanding into Côte d’Ivoire and has a vision for all of francophone West Africa. 8.4  DIGITAL INNOVATIONS IN HEALTH This section contains two case studies in the DRC and M-Tiba: a digital foundation 8.4.2  across the region to stimulate creative thinking on possi- for health financing bilities for innovative health care in low-resource settings. M-Tiba is a mobile health wallet that allows people to use their phones to send, save, and receive digital money that WapiMed: a digital solution for identifying 8.4.1  can be used only for health services and related payments. and accessing health services Developed in Kenya, this product was launched in 2016 WapiMed is an app-based health facility mapping and through the partnership of four important stakeholders: appointment tool developed in 2016 for the DRC (“wapi” Safaricom, the dominant operator in Kenya; CarePay, a means “where” in Swahili). Currently being piloted in Kenyan social venture that manages payments among 80 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O ness has made additional progress, the steps to piloting a mobile health wallet in the DRC would be to 1) iden- tify stakeholders, including public and private providers in existing networks, PharmAccess, CarePay, WapiMed, mobile network operators, and other technical partners, for participation in a pilot of the mobile health wallet; 2) pilot a mobile health wallet in a setting such as Kinshasa or Lubumbashi; and 3) continuously monitor and assess achievements, challenges, and potential for replication and scale of a mobile health wallet. 8.5 RECOMMENDATIONS Clinic piloting M-Tiba in Kenya Review and improve FP and child health indicators in DHIS2 Finding: Currently, DHIS2 FP indicators include the funders, patients, and health care providers and devel- number of specific contraceptive products delivered, oped and administers the openCarePool digital platform some program-related data, and the number of new and on which M-Tiba runs; PharmAccess, the coordinating renewing users. The information provided by these indi- NGO; and Pfizer Foundation, which financially supported cators is limited and does not paint a complete picture the pilot and voucher payments. of FP commodity supply or demand. Because DHIS2 In 2017, M-Tiba began to evolve beyond a simple mobile is relatively new and continues to evolve, there are health wallet with vouchers, to include more-sophisticated opportunities to add and improve variables and collect partnerships with private health insurers, including systematic and actionable data to improve services, Kenya’s National Health Insurance Fund, and a platform reduce stockouts, and track contraceptive prevalence that integrates payment with medical data. By December and demand. Tulane University and UNFPA have indi- 2017, M-Tiba had 805,421 beneficiaries and 465 providers cated that FP indicators are priorities for SNIS updates enrolled in the system (PharmAccess 2017). Additional and are working to improve FP indicators. Similarly, applications supported by M-Tiba rolled out in 2017 child health indicators may warrant review and updating, include HealthConnect, which enables individuals in the which could be done in partnership with United Nations diaspora to channel funds to cover health insurance costs Children’s Fund (UNICEF) and in the context of WHO for Kenyan families, and a mobile cash-advance product IMNCI guidelines. that facilitates digital access to finance for providers. Recommendation: With stakeholders, conduct a multi- One factor in M-Tiba’s success is the digital environment in disciplinary review of DHIS2 to identify where additional Kenya, which is much more favorable than that in the DRC. indicators can be added for FP and child health. Consider In Kenya, mobile phone penetration is 89 percent, mobile which indicators are most critical and feasible for private money penetration is 58 percent, and the dominant oper- sector reporting and use. ator (Safaricom) has 73 percent of the mobile market (Communications Authority of Kenya 2017). In contrast, Survey, map, and register unregistered mobile phone penetration in the DRC is 26 percent, private facilities mobile money penetration is 9 percent, and the domi- nant operator (Vodacom) has 38 percent of the mobile Finding: It is not clear what percentage of private facil- market. A product such as M-Tiba could be successful ities in the DRC is actually registered in DHIS2, making as a long-term goal in the DRC, but it would require a it difficult to collect complete information or to know phased approach with appropriate pilots, training, and whether private facilities that currently participate are networking of private providers and rapid-cycle learning. representative of the whole country. Smaller, poorer When the digital infrastructure and health system readi- facilities in the private sector are not able to meet HEALTH I NFOR MATI O N SYST E M S 81 national registration requirements and are therefore not the Health Data Collaborative for additional resources included in the facility registry. Additionally, updates to to improve the overall functionality and use of the the facility registry are made only once per year, which DHIS2 system. creates a long lag for getting newer facilities into the DHIS2. Develop and distribute simple, actionable Recommendations: data dashboards for decision making in the private sector yy Support a private sector survey to identify, geo-lo- cate, and gather key information about private health Finding: Private providers and implementing partner facilities in the DRC, including pharmacies and drug program managers highlighted the lack of feedback. shops, to facilitate their participation in the DHIS2. Presumably, issues that are identified in public facilities This could be done as part of the planned DPM map- through routine reporting are corrected through action ping of private supply chain stakeholders. by the MSP in its role as steward of public health facili- ties. However, private facilities do not receive any kind of yy Collect information on barriers to formal facility reg- feedback or report on how they are performing relative istration and identify reforms needed to more reg- to other facilities or over time. IMA World Health is work- ularly update the national facility register with new, ing on simple dashboards that can be autogenerated and moved, and closed facilities; this information can be shared with facilities to address concerns about the cur- used to quickly link new facilities into DHIS2 and sup- rent flow data for decision making. Providing feedback port implementation of a new electronic LMIS. to private providers helps motivate them to participate in These activities could be implemented in partnership reporting and allows them to learn from their own data. with the ASPS, as was done in Senegal. Recommendation: Support the development and distri- bution of simple, actionable data dashboards for private Increase usability and relevance of DHIS2 facilities as an incentive to improve the quality and time- data for private sector monitoring liness of reporting by the private sector, and work with IMA World Health to identify indicators that are most Finding: Of the facilities that are registered in DHIS2, a desired, relevant, and actionable for individual private significant number are not categorized as public, private, facilities. or FBO. The current options (public, private, FBO) also limit insight into differences between the private for-profit and nonprofit sectors. In addition, there are no recur- Establish an LMIS and consider ring reports that are generated internally to offer deci- how to integrate private sector sion makers insight into differences in public and private Finding: Current private sector reporting into the LMIS service delivery. The Health Data Collaborative supports is limited, burdensome, and largely paper-based, leading country efforts to improve quality and use of health data to poor data availability and accuracy. Although DHIS2 and has resources to support activities such as harmoni- reforms can help address some data-related issues, DHIS2 zation of incompatible data sets, development of training is not a universal solution. It is less adept at managing packages, and effective use of data. complex, subnational inventory, ordering, quality assur- Recommendations: ance, fleet management, distribution, and other logistics tasks. To address data gaps related to logistics and stock yy Work with DHIS2 stakeholders to create more-specific management, many countries are moving toward the use categories for facilities currently listed as “private” (for of a separate, interoperable platform for LMIS, such as example, nonprofit and for-profit), and ensure that all OpenLMIS. Developing an LMIS platform and integrat- facilities in DHIS2 are correctly tagged as public, FBO, ing it with the DHIS2 system provides a more-nuanced nonprofit, or for-profit. picture of the complex interaction between commodity yy Work with MSP to develop regular reports that high- supply/distribution and service delivery. Although the light sector differences and private sector-specific public sector could manage the LMIS, it would need to challenges and successes. The MSP could reach out to engage the private sector to make the effort a success 82 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O and improve the system’s utility. Government and donors prioritize and harmonize digital solutions to aggregated would need to explore private sector incentives to ensure health needs for data collection, data transmission, sup- their participation. They can build on lessons from Vil- portive supervision, and health communication, among lage Reach implementation of OpenLMIS and work with others. The Digital Health Network could also facilitate UNFPA to evaluate any ongoing electronic LMIS pilots. the development and/or harmonization of interoperable Recommendation: Strengthen the LMIS platform and platforms for data collection, analysis, communication, integrate it with the DHIS2 to help address pervasive sup- supportive supervision, and other key health priorities. ply chain difficulties, such as fraud, stockouts, and waste in both the public and private sectors. Explore opportunities to partner with telecommunications companies to improve Assess, harmonize, and aggregate demand awareness and understanding of health for digital health services in the health sector emergencies, products, and services Finding: Companies such as Orange, Vodacom, Airtel, and Finding: There are many implementing partners in the Africell have physical, virtual, and human networks across DRC who use digital approaches for communicating with the DRC that could be leveraged to improve national beneficiaries, data collection and transmission, supportive communications on urgent health priorities, such as Ebola, supervision and training of health workers and commu- or other essential health products and services. However, nity agents, and financial services. However, there does there is little coordination across public and private actors not appear to be a coordinated approach to partnering in health for communicating with beneficiaries and dis- with telecommunications agencies in these efforts, and seminating information in key health areas. This can lead there are many small-scale contracts for digital services to unclear or redundant messaging and reduction of the for health. Companies such as Orange, Vodacom, Airtel, behavior impact of these messages. and Africell are rarely engaged to help develop digital solutions to pervasive health challenges but instead are Recommendation: After the first DRC Digital Health approached by each organization independently for Workshop, host a more focused session to discuss digital individual needs. This creates inefficiencies for both the service needs for the communication of health informa- health organization, which could otherwise coordinate tion and what a partnership might entail. and aggregate demand for digital services and prod- ucts, and the mobile operator, who must reinvent or Explore opportunities to partner with retailor small-scale services and manage many discrete telecommunications companies to contracts. One potential area for collaboration is the cre- improve data collection and transmission ation of dual roles for health workers as mobile money Finding: DHIS2 data entry and transmission currently agents. This could boost income and promote digital occurs at the health zone level (516 sites), and therefore financial inclusion while providing community sensitiza- Internet and mobile connectivity is not a pressing issue tion around critical health topics. Projects could commit for private providers. However, connectivity for trans- to promoting and using specific operator services, and mitting data was one of the most pervasive challenges operators could provide lower fees in exchange for exclu- noted by the SNIS Division, as well as provincial leadership. sive use of their platform. The tardiness or absence of data caused by poor con- Recommendation: Survey health stakeholders to iden- nectivity can significantly delay decision making and is tify and prioritize interests, challenges, capacity, and particularly problematic in rapidly evolving epidemics. needs for digital health solutions. Convene implement- Furthermore, MEASURE Evaluation is exploring the possi- ing partners, telecommunications agencies, and public bility of decentralizing data entry and transmission to the and private providers to establish a Digital Health Net- health facility level, which means that a more-expansive work, a coordinating body that harmonizes approaches connectivity solution will likely be needed in the next five to digital communication and outreach strategies for key years. Improved telecommunications infrastructure must health priorities. Support the MSP and donors to con- be a priority for negotiations between MNOs and MSP. vene biannual meetings of the Digital Health Network to A PPP between mobile network operators, implementing HEALTH I NFOR MATI O N SYST E M S 83 partners, and the MSP may help address the complex chal- use advanced visualization and organization tech- lenge of data connectivity. niques to provide actionable and timely data from the central, provincial, health zone, facility, and community Recommendation: After the first DRC Digital Health levels while keeping its commitment to avoid parallel Workshop, host a more-focused session to discuss digital systems and not duplicate effort. The IHP project is service needs for the collection and transmission of health focused on public sector, so private sector data may data and what a partnership might entail. not have been as fully considered during the proposal period. Ensure private sector integration in new Recommendation: Consider how to integrate relevant IHP data dashboard private sector indicators into this dashboard at its con- Finding: The IHP project is initiating a data dashboard ception so that the dashboard is applicable to the total for health program decision making. This system will health system. 84 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O 9.  Three-Year Road Map for Action During the validation workshop in Kinshasa, participants the recommendations noted previously. The participants from the public and private stakeholders validated the prioritized a few key activities by pillar, which are high- Three-Year Road Map for Action developed based on lighted in blue. THR EE-Y EAR R OAD MAP FO R AC T IO N 85 86 Three-year road map for action to engage the private sector in improving the performance of the health system in the DRC Lead Year 1 Year 2 Year 3 No. Activity Organization Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Leadership and Governance 1 Support the establishment of an Order of Midwives 1.1 Convene advocacy meetings with the Société Congolaise SCPSF, MSP X X X X de la Practice de Sages-Femmes (SCPSF) and MSP 1.2 Assist with the Order’s legal cadre SCPSF, MSP X X 1.3 Launch the Order in Kinshasa SCPSF, MSP X X 1.4 Roll out the Order to provinces SCPSF, MSP X X X X 1.5 Create a database and a website for the Order of Midwives SCPSF, MSP X X X X X X 1.6 Organize meetings to encourage midwives to register in the SCPSF, MSP X X X X X X Order 2 Conduct a legal and regulatory review 2.1 Develop and approve the scope of work for the legal and ASPS, MSP X regulatory review 2.2 Conduct the legal and regulatory research ASPS, MSP X 2.3 Convene the MSP, ASPS to prioritize legal changes and ASPS X X identify next steps 2.4 Convene MSP/ASPS advocacy meetings to change laws ASPS, MSP X X X X X X X 2.5 Assist the ASPS to disseminate new laws and regulations ASPS X X to the private sector 3 Support the ASPS to assume a stronger leadership role within the private sector and with the government 3.1 Conduct institutional analysis and benchmarking to ASPS X X assess ASPS’s financial, programmatic, and organizational performance and needs 3.2 Develop a tailored capacity-building plan ASPS, MSP X X 3.3 Develop ASPS’s advocacy plan focused on priority issues ASPS X X X such as quality, taxes, and shared resources with public sector 3.4 Create a database, a website, and social media accounts ASPS, MSP X X X T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O for the ASPS 3.5 Review ASPS’s membership to identify constituencies ASPS X X lacking representation 3.6 Develop a resource mobilization plan ASPS X X 3.7 Establish regional ASPS branches to address health ASPS, MSP X X X X priorities in each province 3.8 Link the ASPS with the Central Africa Healthcare ASPS X X Federation and the Africa Healthcare Federation 4 Leverage and build the capacity of the ASPS in adding value to the private health sector (including through business training activities detailed here) 4.1 Develop guidelines and checklists for providers to MSP, Orders, ASPS X X understand regulatory requirements to maintain their professional accreditation and ensure that their health care businesses are properly registered 4.2 Maintain a member database that financial institutions ASPS X X X X X X X X X X (FIs) can consult to verify licensing/certification status of health providers seeking to borrow from the FI 4.3 Offer a forum for FIs and private providers to discuss ASPS, Orders X X X X X X X X X X X X concerns 4.4 Organize trade fairs to connect health providers to FIs and ASPS, FI, companies X X X X other business input suppliers 4.5 Support sectoral studies on topics such as how to improve ASPS X X X the supply and maintenance of medical equipment in the DRC or identifying specific financing needs of female providers or FBOs 4.6 Evaluate the potential to structure a risk mitigation ASPS X X X instrument, such as a mutual guarantee fund, that would be available to members of the ASPS that meet minimum requirements 5 Launch national- and district-level public–private dialogue forums 5.1 Establish a small technical committee at the national level CNP-SS, ASPS X X X X X X X X X X X X to meet monthly or quarterly 5.2 Establish public–private dialogue forums at the health DPS, ASPS, HZ X X X X X X X X X X X X zone level by 1) conducting training of trainers with DPS staff, who then 2) repurpose existing health zone (HZ) level platforms with public and private sector stakeholders (continues on page 88) THR EE-Y EAR R OAD MAP FO R AC T IO N 87 88 Three-year road map for action to engage the private sector in improving the performance of the health system in the DRC  (Continued ) Lead Year 1 Year 2 Year 3 No. Activity Organization Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 5.3 Create communication and awareness-raising tools to ASPS, MSP X X X X X X X X X X X X support the forums 6 Move forward with finalizing the FBO convention 6.1 Convene FBO-MSP meetings to finalize memorandum of FBOs, MSP X X understanding (MOU) negotiations with FBOs 7 Build the MSP’s capacity to better leverage PPPs 7.1 Launch a private sector cellule that reports directly to the MSP—Dir. Partenariat X X X Secrétaire General 7.2 Clarify the role of the Division Partenariat et MSP—Dir. Partenariat X X X Contractualisation within the Direction de Soins et Partenariat and with the proposed private sector cellule 8 Develop a health PPP strategy to guide MSP’s partnership activities 8.1 Convene meetings to develop a PPP strategy for health MSP, ASPS X X X X X aligned with the Vadé Mécum du Partenariat 8.2 Develop a template to rate potential PPPs and train MSP MSP, ASPS X X staff on use 8.3 Develop a preliminary list of PPPs to consider MSP, ASPS X X 9 Collaborate with pharmaceutical and medical device companies to improve access to and delivery of health services 9.1 Assess promising pharma and medical devices to bring/ MSP, companies X X scale up 9.2 Convene one-on-one meetings with promising pharma MSP, companies X X X X X X X X X X and medical device makers to discuss partnership opportunities (as needed) 10 Partner with companies piloting and developing technologies with potential applications in the health system 10.1 Convene meetings as needed to consult with technology MSP, ASPS X X X X X X companies when considering the implementation of new programs and/or reforms across the health system (specific collaboration opportunities are outlined in Activities 41, 47, 48, and 49) T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Service Delivery 11 Collect additional information on service delivery in the private sector 11.1 Integrate questions regarding the private sector in MSP, ASPS, Conseil X X X X X X X X X X X X upcoming studies and invest in complementary studies National des ONG de santé (CNOS), international NGO (INGO) 12 Strengthen private provider access to clinical trainings, especially for FP 12.1 Through the eproductive, maternal, newborn and child MSP, ASPS, CNOS X X health (RMNCH) indicators developed in DHIS2 or, through another identification approach, identify private providers that may need clinical training in FP and/or other health priority areas 12.2 Establish a “target and train” pilot program in partnership MSP, ABEF X X with PSI and ABEF for rapid, clustered clinical training that is equitably distributed across regions and provider types 12.3 Implement training program and monitor change in key MSP, ABEF X X X X outcome indicators 13 Invest in programs that address cost barriers to FP services in the private sector 13.1 Assess feasibility and cost–benefit of implementing a MSP, ASPS X X X X FP voucher program to encourage both the offer of and demand for FP services in private facilities 13.2 Partner with private providers to determine how they can MSP, ASPS X X contribute to and participate in a voucher program 13.3 Pilot, monitor/evaluate the success, and adjust/scale of MSP, ASPS X X X X X X X X program(s), tracking key FP indicators 14 Leverage an integrated four-pronged approach to improve child health case management (Lubumbashi) 14.1 Supply 14.1.1 Conduct a private sector supply chain bottleneck MSP, ASPS, X X assessment for IMNCI commodities to private providers, Fédération des pharmacies, and drug shops to determine availability of Entreprises du Congo IMCNI products in the private sector (FEC) (continues on page 90) THR EE-Y EAR R OAD MAP FO R AC T IO N 89 90 Three-year road map for action to engage the private sector in improving the performance of the health system in the DRC  (Continued ) Lead Year 1 Year 2 Year 3 No. Activity Organization Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 14.1.2 Based on the results from the supply chain assessment, MSP, FEDECAME, X X work with the private sector manufacturers/importers/ ASPS, FEC distributers/wholesalers (identified in landscape assessment mentioned in Activity 13.1.5) to develop/improve standard resupply systems to ensure that products flow efficiently through the supply chain based on private sector need 14.1.3 Train private sector providers, pharmacists, and drug shop MSP X X counter agents in supply chain fundamentals and resupply processes 14.1.4 Provide support to FEDECAME to strengthen national PNAME, FEDECAME, X X quantification and procurement coordination for IMNCI INGOs commodities 14.1.5 Conduct a landscape assessment of local manufacturers/ MSP, ASPS X X importers/distributers/wholesalers of IMNCI commodities, including a mapping of major suppliers/distributors and the distribution process, including key barriers to availability 14.1.6 Present a business case to local manufacturers/importers/ MSP, INGOs, ASPS X X distributers/wholesalers highlighting estimates of demand of IMNCI commodities, including government/institutional procurement 14.1.7 Create and organize a yearly supplier forum consisting of MSP X X X local manufacturers/importers/distributers/wholesalers/ retailers (drug shop owners) of IMNCI commodities 14.2 Demand generation 14.2.1 Conduct a situation analysis to understand both provider MSP X X and caregiver knowledge on IMNCI caregiving practices 14.2.2 Identify target audience and specific behavior change goals MSP X X 14.2.3 Develop key messages MSP X X 14.2.4 Select activities and interventions MSP X 14.2.5 Conduct and assess the IMNCI demand generation MSP X X X X X X X campaign 14.3 Capacity building 14.3.1 Ensure that all health zones have the IMNCI guidelines and MSP, ASPS X X T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O materials for all private health facilities 14.3.2 Conduct trainings by health professional cadre (private MSP, ASPS X X X providers, pharmacists, and counter agents) 14.3.3 Ensure/establish a system of supportive supervision for MSP, ASPS X X private sector health care to improve knowledge and skills of pharmacists and counter agents specifically 14.3.4 Gather data through the supportive supervision activity, MSP, ASPS X X X X X X X X X which will be used to follow up with pharmacists and counter agents in need of additional training 14.3.5 Roll out an accreditation process for the trained MSP, ASPS X X X X X X X X X pharmacists and counter agents 15 Increase private sector engagement in nutrition programs (Lubumbashi) 15.1 Organize and launch a private sector nutrition network MSP—PRONANUT/ X X X with yearly meetings to encourage involvement in locally UNICEF, ASPS, FEC manufactured nutrition products, which could also lead to private sector engagement in transporting therapeutic products to difficult-to-access areas and the promotion of local food fortification 15.2 Conduct an analysis to determine existing prepackaged MSP—PRONANUT, X X local nutrition foods presently sold in Lubumbashi private ASPS, FEC, clinics companies 15.3 Based on analysis conducted, determine the viability MSP—PRONANUT, X X of engaging private suppliers to package high-quality, companies nutritious products in small quantities in exchange for government-supported, demand-generation activities promoting such foods 15.4 Based on results of viability analysis, organize one-on-one MSP—PRONANUT, X X X X X X X X meetings to discuss specific partnership opportunities (as FEC, companies needed) Access to Essential Medicines 16 Continue to provide technical support to the FEDECAME system 16.1 Convene meetings, as needed, to identify opportunities to MSP—DPM X X X X X X include technical assistance in cost controls, marketing, and risk management around bad debt, overstocks, and competition; and governance in partners’ programs of support THR EE-Y EAR R OAD MAP FO R AC T IO N (continues on page 92) 91 92 Three-year road map for action to engage the private sector in improving the performance of the health system in the DRC  (Continued ) Lead Year 1 Year 2 Year 3 No. Activity Organization Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 17 Support CDRs to better manage their bad debt risk 17.1 Convene meetings with FEDECAME network and partners MSP—DPM X X X to explore ways to increase their access to operating capital and identify ways to minimize their risk from bad debts 18 Encourage collaboration among donors, international NGOs, and the FEDECAME system 18.1 Convene coordination meetings, as needed, with PNAME, FEDECAME, X X X FEDECAME, PNAME, and other stakeholders to assist with international NGOs forecasting of needs, procurement, and distribution and improve CDR planning and risk reduction 18.2 Continue and/or expand the existing practice of PNAME, FEDECAME, X X X X X X X X X X X X contracting storage and distribution to CDRs international NGOs 19 Invest in the logistical capacity of the supply chain 19.1 Conduct regional analyses of the transport sector MSP—DPM, PNAME X X X 19.2 Provide targeted capacity-building to the companies with MSP—DPM, PNAM X X X X X X X X X the largest and best-managed distribution networks regarding the transport of medicines (for example, disseminate requirements, build cold chain capacity, and so on) 19.3 Prequalify these companies to work with the government MSP—DPM, PNAM X X X and other stakeholders (for example, CDRs, private wholesalers, international NGOs) 20 Comprehensive reform of the commercial pharmaceutical sector 20.1 Define new scope of practice for second-tier drug shops, MSP—DPM, Order of X X X X including training curriculum for drug shop operators Pharmacists, medical schools, ASPS 20.2 Conduct participatory review and development of MSP—DPM X X X X regulations on pharmaceutical wholesaler practice to support the new scope of practice for second-tier drug shops T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O 20.3 Provide training and support to help existing drug shops MSP—DPM, Order of X X X X adapt to the new scope of practice Pharmacists, ASPS 20.4 Design and implement communications campaign to the MSP—DPM, X X X X public about the new drug shop scope and the risks of contracted substandard medicines communications agencies 20.5 Strengthen the logistical and enforcement capacity of the MSP, Inspection X X X X X X DPM Générale de la Santé (IGS), Ministry of Justice 20.6 Inspect and close noncompliant drug shops and MSP, IGS, Ministry of X X X X wholesalers Justice 20.7 Advocate for long-term budget allocations to launch and MSP, IGS, Ministry of X X X X X X X X maintain monitoring of drug shops by the government Finance 21 Encourage the creation of pharmacy and drug shop networks 21.1 Convene meetings, as needed, with large pharmacies to MSP, Order of X X X X advocate for the expansion of drug outlet networks Pharmacists, ASPS 21.2 Advocate with banks and donors to increase access to Order of X X X X financing to support the expansion of drug outlet networks Pharmacists, ASPS, (as needed) Commercial Banks 22 Evaluate the feasibility of revising the customs and taxation regime to incentivize local manufacturing 22.1 Assess the feasibility of revising the customs and taxation Ministry of Finance, X X regime to incentivize local manufacturing MSP, ASPS 22.2 Advocate for the reform of the customs/import tax regime Ministry of Finance, X X X MSP, ASPS 23 Provide technical support to local and international manufacturers with the most potential 23.1 Conduct a market study to identify medicines that MSP—DPM, WHO X X international organizations are most likely to procure locally and determine where local manufacturers have the greatest comparative advantages 23.2 Identify opportunities for international manufacturers to MSP—DPM, WHO, invest in opening a local manufacturing plant in the DRC IFC (continues on page 94) THR EE-Y EAR R OAD MAP FO R AC T IO N 93 94 Three-year road map for action to engage the private sector in improving the performance of the health system in the DRC  (Continued ) Lead Year 1 Year 2 Year 3 No. Activity Organization Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 23.3 Provide technical assistance and technical quality MSP - DPM, WHO, X X X X X X X X assurance support to local and international IFC manufacturers 24 Establish a searchable web-based database of registered drugs and develop anticounterfeit approach 24.1 Translate existing PDF list of registered drugs available on MSP—DPM, PNAME X X X the DPM website into interactive, searchable database 24.2 Convene key pharmaceutical manufacturers, regulatory/ MSP­–DPM, PNAME X X X pharmacovigilance authorities, and potential technology partners (mPedigree) to discuss the size, scope, and specific needs for an improved tracking and anticounterfeit solution 24.3 Invest in and deploy an anticounterfeit and pharmaceutical MSP—DPM X X X X X X monitoring solution Financing HEALTH FINANCING 25 Increase engagement of mutuelles and other health-financing mechanisms 25.1 Review relevant regulation and policies and summarize MSP—PNPMS, X main topics/areas for engagement of mutuelles and other POMUCO, UMUSAC health-financing mechanisms 25.2 Identify stakeholders (government, civil society, employers, MSP—PNPMS, X X mutuelles and other health-financing programs, POMUCO, UMUSAC development partners, and so on) to participate in advocacy forums 25.3 Conduct survey/interviews with stakeholders to establish MSP—PNPMS, X X priorities to increase private sector participation in POMUCO, UMUSAC mutuelles and other health-financing programs 25.4 Draft/validate action plan and objectives to advocate MSP—PNPMS, X X for engagement of mutuelles and other health-financing POMUCO, UMUSAC programs 25.5 Convene/participate in advocacy forums and activities MSP—PNPMS, X X X T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O POMUCO, UMUSAC 26 Strengthen health-financing programs 26.1 Convene stakeholders to prioritize capacity-building needs MSP, POMUCO X for mutuelles and other health-financing programs and (CGAT), UMUSAC relevant support organizations 26.2 Develop technical assistance interventions in partnership MSP, POMUCO X X with mutuelle and other health financing support (Centre de Gestion organizations de Risque et d’Accompagnement Technique des Mutuelles de Santé - CGAT), UMUSAC 26.3 Implement technical assistance for mutuelles and other MSP, POMUCO X X X X X X X X X health financing programs (CGAT), UMUSAC 26.4 Identify employer sponsor and/or TPA to support improved MSP, FEC or X X coverage and efficiency of employee benefit programs employer, To Be Determined (TBD) ; TPA TBD 26.5 Develop technical assistance interventions with corporate MSP, FEC or X X benefit plan sponsor employer, TBD; TPA TBD 26.6 Implement technical assistance with corporate health plan MSP, FEC or X X X X sponsor/TPA employer, TBD; TPA TBD 27 Work with health-financing programs to cover FP and preventive health services 27.1 Survey major mutuelle programs and employers to MSP, POMUCO, X X document coverage of FP and preventive health services UMUSAC, FEC 27.2 Develop/assess the business case to expand coverage of MSP, POMUCO, X X FP and preventive health services UMUSAC, FEC 27.3 Develop and implement advocacy plan to support MSP, POMUCO, X X X X X X X X expanding coverage of FP and preventive health services UMUSAC, FEC, ASPS (continues on page 96) THR EE-Y EAR R OAD MAP FO R AC T IO N 95 96 Three-year road map for action to engage the private sector in improving the performance of the health system in the DRC  (Continued ) Lead Year 1 Year 2 Year 3 No. Activity Organization Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 28 Build on lessons from existing health-financing programs 28.1 Document experience of existing health-financing POMUCO, UMUSAC, X programs, including MESP MESP, MSP, ASPS, Orders 28.2 Synthesize and disseminate lessons learned by existing POMUCO, UMUSAC, X health-financing programs, including MESP, to develop and MESP, MSP, ASPS, scale up coverage Orders 28.3 Identify potential areas of technical assistance to support POMUCO, UMUSAC, X X health-financing programs, including MESP, to expand MESP, MSP coverage and strengthen its financial sustainability 28.4 Implement technical assistance POMUCO, UMUSAC, X X X X X X X MESP, MSP 28.5 Develop demonstration case for expanding insurance POMUCO, UMUSAC, X X coverage based on experience of existing health-financing MESP, MSP programs 28.6 Disseminate demonstration case POMUCO, UMUSAC, X MESP, MSP 29 Strengthen private providers’ ability to participate in health-financing initiatives 29.1 Select location to pilot private provider (and/or for-profit) MSP, ASPS, FBOs X engagement in health-financing initiatives 29.2 Identify group(s) of providers who could form a private MSP, ASPS, FBOs X X provider network 29.3 Determine objectives and focus of technical assistance MSP, ASPS, FBOs X with selected providers 29.4 Develop work plan and design technical assistance (for MSP, ASPS, FBOs X example, interventions for treatment protocols, payment mechanisms, billing standards) 29.5 Implement technical assistance MSP, ASPS, FBOs X X X X X X X 29.6 Conduct a rapid assessment to identify corporate sponsor MSP, corporate X X of health benefit program and/or TPA to collaborate with sponsor, TPA, private provider network to deliver better-quality, more- provider network efficient health services T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O 29.7 Establish MOU for partnership between a private provider MSP, corporate X network and a corporate sponsor of a health benefit sponsor, TPA, program and/or TPA provider network 29.8 Provide technical assistance to support partnership MSP, corporate X X X sponsor, TPA, provider network 30 Develop a culture of insurance 30.1 Establish point of contact at ARCA and working group to ARCA, MSP, ASPS, X promote development of demand/supply of insurance Orders 30.2 Convene working group and develop MOU for activities ARCA, MSP, ASPS, X X X Orders 30.3 Collaborate with ARCA to educate consumers about health ARCA, MSP, ASPS, X X X X X X X X insurance (for example, develop/conduct media campaigns Orders to inform consumers that health insurance can be a valuable way to be protected against catastrophic costs for health care) 30.4 Identify private sector champion(s) and develop advocacy ARCA, MSP, ASPS, X plan to promote purpose and value of insurance Orders 30.5 Identify insurance and potential insurance distribution Private insurer, X X partner(s) to provide technical assistance (for example, and potential market research, market sensitization) to launch a simple distribution/ health insurance product technology partner(s) (telecom, MFI, cooperative) 30.6 Provide technical assistance to launch the health insurance Private insurer, and X X X X product potential distribution/ technology partner(s) (telecom, MFIs, cooperative) 31 Identify the role of PBF in improving the performance of private providers 31.1 Conduct desk research, interviews to confirm existing and MSP, ASPS X X planned efforts for PBF, including role of private providers 31.2 Identify opportunities for existing programs to engage MSP, ASPS X private providers 31.3 Test whether and how PBF programs can promote quality MSP, ASPS X X X X X X and efficiency among private providers THR EE-Y EAR R OAD MAP FO R AC T IO N 31.4 Disseminate findings MSP, ASPS X (continues on page 98) 97 98 Three-year road map for action to engage the private sector in improving the performance of the health system in the DRC  (Continued ) Lead Year 1 Year 2 Year 3 No. Activity Organization Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 ACCESS TO FINANCE 32 Provide business and financial management training and counseling for private health providers. 32.1 Conduct an assessment of the needs of private health ASPS, Orders, X X providers for business training Business development service (BDS) provider 32.2 Develop a training program based on the needs ASPS, Orders, BDS X X X assessment and the results of initial training sessions provider 32.3 Provide business training courses to private health ASPS, Orders, BDS X X X X X X X X X providers and training of trainers within professional provider organizations 32.4 Provide individual, one-on-one counseling for selected ASPS, Orders, BDS X X X X X X X X providers who demonstrate the highest potential for provider improving quality and growing their practices 32.5 Coordinate business training and counseling with clinical ASPS, Orders, BDS X X X X X X X X training and accreditation steps recommended under the provider Health Workforce section 33 Work with financial institutions to expand lending to the health sector 33.1 Establish and implement a risk-sharing mechanism or Donors, financial X X X X X X X X X X X X mechanisms, such as a USAID DCA portfolio guarantee or institutions, ASPS, other type(s) of guarantee fund MSP, Ministry of Finance 33.2 Explore options to identify and implement medium- or Donors, financial X X X X longer-term funding for financial institutions to better institutions, ASPS meet the financing needs of the health sector 33.3 Assist financial institutions to conduct process evaluations Financial institutions, X X X X X X to improve efficiency by identifying and addressing Implementing operational weaknesses to reduce overall costs partners (IPs) T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O 33.4 Work with financial institutions to develop financial Financial institutions, X X X X X X products adapted to the needs of private health providers IP 33.5 Provide training, information on the private health sector, Financial institutions, X X X X X X X and technical assistance to financial institutions IP, ASPS, MSP 34 Establish partnerships to increase access to finance for key investments 34.1 Evaluate the potential to develop partnerships and market Financial institutions, X X X X X X X X links (for example, between financial institutions and companies, IP, ASPS, medical equipment suppliers) within the health ecosystem MSP that would generate benefits to all parties 34.2 Convene one-on-one meetings with interested Financial institutions, X X X X X X X X stakeholders to discuss specific partnership opportunities MSP, companies, IP (as needed) 35 Link health to health enterprise and innovation activities 35.1 Assess the landscape for health enterprises and determine ASPS, MSP X X the most promising activities to jump-start health companies 35.2 Convene workshop to determine next steps and develop an ASPS, MSP X action plan Health Workforce 36 Improve coordination among stakeholders involved in HRH management 36.1 Establish a formal collaboration framework between MSP’s MSP, MOE, MHE X X X X new Human Resource Office, Ministry of Education (MOE), and Ministry of Higher Education (MHE) 36.2 Develop and implement a collaboration framework Orders, private X X X X X X X X between the Orders, private health associations (for health associations, example, ASPS) and MSP MSP (continues on page 100) THR EE-Y EAR R OAD MAP FO R AC T IO N 99 100 Three-year road map for action to engage the private sector in improving the performance of the health system in the DRC  (Continued ) Lead Year 1 Year 2 Year 3 No. Activity Organization Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 37 Establish and enforce the accreditation system for training institutions 37.1 Support the MSP, MOE, and MHE to revise norms for the MSP, MOE, MHE X X X accreditation of health training schools 37.2 Support the MSP, MOE, and MHE to implement the revised MSP, MOE, MHE X X X X X X X X norms 38 Build public–private links to facilitate practical training 38.1 Convene meetings with the MSP, MOE, MHE, and PMTIs to MSP, MOE, MHE, X X X X clarify and codify standard operating procedures related to PMTI the placement of students from PMTI in public facilities 38.2 Convene meetings with the MSP, MOE, MHE, PMTI, and MSP, MOE, MHE, X X X X provider networks (FBOs and ASPS) to design and pilot a PMTI, FBOs, ASPS practicum model for the private sector 39 Increase the quality and accessibility of training 39.1 Support the MSP to revise and harmonize health training MSP, MOE, MHE, X X X X schools’ curricula Orders 39.2 Support the MSP, MOE, and MHE to set up training MSP, MOE, MHE, X X X institutions for trainers based on the Yaoundé training Orders centers 39.3 Support the MOE, MHE, and MSP to develop and pilot MSP, MOE, MHE X X X X X X a scholarship program to enable providers to acquire relevant skills in targeted health zones 39.4 Support the MOE, MHE, and MSP to explore opportunities MSP, MOE, MHE, X X X X X X to increase the accessibility of training through the Orders, ASPS development of an e-Learning platform 40 Identify and address HRH gaps in collaboration with partners 40.1 Convene workshop with all relevant partners to develop a MSP, ASPS X X road map to address HRH gaps in the public and private sector based on the findings of the mapping of public facilities and the survey of private facilities (Activity 43) 40.2 Support the Orders and private health professional MSP, Orders, X X associations to establish and/or update their member Health professional databases based on the findings of the survey (Activity 43) associations T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O 41 Incorporate the private for-profit sector in the MSP’s HRH staffing planning 41.1 Convene meetings to integrate the private for-profit sector MSP, ASPS X X X X X in HRH staffing plans 41.2 Establish and develop contracting mechanisms in MSP, Ministry of X X X exchange for tax relief, as is done with the nonprofit sector, Finance based on the HRH road map (Activity 38.1) 42 Implement a systematic approach to increase HRH motivation 42.1 Convene meetings, as needed, to develop and implement MSP, MOE, MHE, X X X a systematic approach to increase HRH motivation to Orders, ASPS improve quality in the public and private sector Health Information Systems 43 Improve and add FP and child health indicators in DHIS2 43.1 Convene workshop to include MSP–Division Système MSP-DSNIS, Orders, X X X National d’Information Sanitaire (DSNIS), UNICEF, UNFPA, ASPS and WHO to identify, prioritize, and operationalize key RMNCH indicators to include in DHIS2 43.2 Work with implementing partners and health programs to MSP-DSNIS X X further integrate and operationalize indicators in routine data collection 44 Survey, map, and register in DHIS2 newly identified private facilities 44.1 Develop sampling strategy and identify priority data points MSP-DSNIS/DPS, X X X X for a nationally representative survey of pharmacies, drug Orders, ASPS, FBOs shops, and unregistered private health facilities 44.2 Conduct the survey MSP-DSNIS/DPS, X X X X X X Orders, ASPS, FBOs 44.3 Disseminate survey results and establish a strategy for MSP-DSNIS/DPS, X X X improved integration of private sector in national health Orders, ASPS, FBOs information systems 45 Increase usability and relevance of DHIS2 data for private sector actors 45.1 Conduct stakeholder interviews to better understand the MSP-DSNIS/DPS, X X X X functional differences between for-profit, nonprofit, FBO, Orders, ASPS, FBOs NGO, and public facility classifications; finalize and publish clear definitions for each category 45.2 Require facilities to self-identify based on official published MSP-DPS/DSNIS X X X X categories THR EE-Y EAR R OAD MAP FO R AC T IO N (continues on page 102) 101 102 Three-year road map for action to engage the private sector in improving the performance of the health system in the DRC  (Continued ) Lead Year 1 Year 2 Year 3 No. Activity Organization Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 45.3 Revise and complete the classification of private sector MSP-DSNIS/DPS X X X X facilities registered in DHIS2 45.4 Develop dashboard for key variables and disparities MSP-DSNIS/DPS X X X X between public and private facilities that are important to track over time based on strategy for private sector inclusion 46 Develop and distribute simple, actionable data dashboards for decision making in the private sector 46.1 Convene a sample of providers at different facility levels MSP-DSNIS, ASPS, X X X X and across FBO/private/public types registered in DHIS2 IMA World Health and pilot sample dashboards for dissemination to facilities 46.2 Integrate dashboard restitution into existing monthly MSP-DSNIS, IMA X X X X X X X X validation meetings at the HZ level World Health 47 Establish an LMIS and consider how to include private sector actors 47.1 Convene key supply chain stakeholders (MSP-DPM, CDR, MSP-DPM, PNAME, X X X X X X VillageReach, UNFPA, FEDECAME, technology partners) to ASPS develop a road map for selecting a national LMIS platform, developing national policies and protocols, establishing an empowered implementation oversight committee, and ensuring integration with DHIS2 and inclusion of private sector 47.2 Pilot LMIS platform with subset of priority products and MSP-DPM X X X X X X essential medicines 47.3 Continue rapid cycle monitoring, evaluation, and MSP-DPM X X X X X improvement activities; revise reporting, distribution, and monitoring functions accordingly 48 Assess, harmonize, and aggregate demand for digital health services in the health sector 48.1 Design and conduct a baseline survey on current digital MSP X X X X services use and needs among public and private health stakeholders, focusing on the domains of communication with beneficiaries, data collection/transmission, supportive supervision of health agents and providers, and T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O digital financial services 48.2 Convene public and private health stakeholders and MSP X telecommunications agencies in a Digital Health Workshop to 1) share survey results and identify priority area for digital service investment and harmonization across health stakeholders and 2) determine interest in establishing a working group to support interoperable, harmonized digital systems across health stakeholders 48.3 Convene the digital health working group to continue to MSP X X X X support digital investments and harmonization across health stakeholders and facilitate the development of MOU with MNO to establish priority partnership 49 Explore opportunities to partner with telecommunications companies to improve awareness and understanding of health emergencies, products, and services 49.1 After the first DRC Digital Health Workshop, host a more- MSP X X focused session to discuss MNO-MSP-IP partnership for health communication across DRC 49.2 Organize one-on-one meetings to discuss specific MSP X X X X X X partnership opportunities (as needed) 50 Explore opportunities to partner with telecommunications companies to improve data collection and transmission 50.1 After the first DRC Digital Health Workshop, host a more- MSP X X focused session to discuss MNO-MSP-IP partnership for data collection and transmission 50.2 Organize one-on-one meetings to discuss specific MSP X X X X X X partnership opportunities (as needed) 51 Ensure private sector integration in new IHP data dashboard 51.1 Convene public and private stakeholders to shape the MSP, IHP, ASPS X X X X development, implementation, and use of the IHP data dashboard THR EE-Y EAR R OAD MAP FO R AC T IO N 103 10. Conclusion This document, The Role of the Private Sector in Improv­ Taken together, these three deliverables help clarify the ing the Performance of the Health System in the Demo­ role of the private sector in improving the health sys- cratic Republic of Congo, has three parts: 1) a current tem to support the MSP, the World Bank, USAID, donors, state assessment based on desk research, which provides and other key stakeholders in enhancing public–private a snapshot of the current role of the private sector using engagement at all levels of the health system. The infor- the WHO building blocks (leadership/governance, service mation presented in this report is intended to create an delivery, access to essential medicines, financing, health opportunity for multisectoral dialogue, fostering a health workforce, and health information systems); 2) findings system that leverages the skills, resources, and talents of and recommendations using the WHO health pillars as a all health actors to achieve the goal of high-quality health framework; and 3) the Three-Year Road Map for Action, care accessible to all in the DRC. which is to be used as an implementation guide. 104 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Appendices ANNEX A. SCOPE OF WORK yy évaluer la contribution du secteur privé à l’économie nationale et au budget national, Contexte yy stimuler les investissements privés dans le secteur de Le gouvernement s’est engagé depuis de nombreuses la santé. d’années à renforcer le système de santé en lançant un certain nombre de réformes adressant les défis liés aux piliers du système congolais, à savoir, les faiblesses au Étapes niveau des prestations de services de santé, de l’accessibil- L’approche d’Abt Associates divise les activités de l’éval- ité des produits et technologies pharmaceutiques et médi- uation du secteur privé en quatre étapes principales : caux, des solutions de financement de la santé, des sys- tèmes d’information sanitaires, des ressources humaines, 1. Planification : Au cours de cette étape, l’équipe RDC et enfin, de la gouvernance générale du système. de la Banque Mondiale a finalisé la portée de l’éval- uation, le calendrier de mise en úuvre et la liste des Dans la perspective de mieux orienter le Ministère et les principaux intervenants pour les entrevues avec les partenaires de développement dans leurs stratégies et informateurs clés. investissements en vue du renforcement du système de santé de la RDC, la Banque Mondiale, en partenariat avec 2. Revue de la littérature et analyse des données : IFC, la Fondation Bill et Melinda Gates et l’USAID, a mis l’équipe a effectué une revue documentaire, com- en úuvre une étude portant sur l’évaluation du secteur plété une analyse de segmentation de marché basée privé de la santé. Cette évaluation est conduite par Abt sur cette revue, développé des questions adaptées Associates en collaboration étroite avec le Ministère de aux différentes parties prenantes pour les entrev- la Santé Publique. ues et rédigé le plan et l’ébauche de l’Évaluation de l’état actuel, qui comprend les conclusions initiales Objectifs sur les contributions du secteur privé aux domaines de santé clés. L’évaluation du secteur privé s’inscrit pleinement dans la lignée des réformes en cours. En effet, le secteur privé 3. Travail sur le terrain : la troisième étape de l’évaluation (lucratif, confessionnel et associatif) qui fait déjà par- se concentre sur la collecte et l’analyse d’informations tie intégrante du système sanitaire congolais, a un rôle supplémentaires. L’équipe technique d’Abt Associates essentiel à jouer dans la matérialisation de la vision du se rendra en RDC fin novembre/début décembre pour gouvernement de services de santé abordables et de mener des entrevues avec des informateurs clés et des qualité, accessibles à tous. En soutenant cette évalua- visites sur le terrain pour combler les lacunes d’infor- tion, le gouvernement entend ainsi: mation identifiées durant la recherche documentaire yy comprendre les dynamiques et la structure du sec- et commencer à élaborer des recommandations. teur privé afin de mieux l’intégrer dans la mise en 4. Validation, priorisation et finalisation : les activi- úuvre des programmes de renforcement du système tés de cette étape sont la finalisation de l’Évaluation de santé, de l’opportunité, des priorités stratégiques et de la yy identifier les mesures à prendre pour créer un cadre Feuille de route pour l’action. Au cours de l’atelier, les réglementaire propice au développement d’un sec- intervenants des secteurs public, privé et bailleurs teur privé partenaire du public dans la santé, valideront les résultats de l’évaluation, prioriseront AP P E NDIC E S 105 les recommandations, élaboreront un plan pour la Médicaments et technologies mise en úuvre des recommandations et finaliseront yy La vente ou la distribution de produits pharmaceu- le rapport. tiques est-elle suffisamment règlementée (particu- lièrement en ce qui concerne la planification familiale et la santé maternelle et infantile) ? Entrevues avec les parties prenantes yy Quels sont les principaux défis et opportunités dans Lors des entrevues avec les parties prenantes du le secteur privé par rapport à la vente/distribution 20 novembre au 15 décembre, l’équipe d’Abt Associates et la généralisation de produits de planification famil- posera une vaste gamme de questions adaptées aux dif- iale, santé maternelle et infantile, et autres ? férentes catégories de parties prenantes, comme l’illustre la liste de questions ci-dessous. Financement yy Quels sont les défis et les opportunités pour les Liste de questions à titre illustratif différents programmes de financement de la santé Gouvernance (publics et privés) ? Quelles sont les prochaines yy Quelles sont les politiques du gouvernement face aux étapes immédiates envisagées pour progresser ? prestataires privés offrant des services de planifica- yy Est-ce que les prestataires privés participent dans les tion familiale, santé maternelle et infantile et autres différents programmes de financement de la santé ? services ? Pourquoi ou pourquoi pas ? yy Quels types de collaboration existent-ils entre le gou- yy Les prestataires privés ont-ils accès à des finance- vernement, les confessionnelles/ONG, et les autres ments ou des formations en gestion ? Si oui, d’où structures du secteur privé, particulièrement en ce proviennent-ils ? qui concerne la planification familiale et la sante maternelle et infantile ? yy Quelles sont les contraintes principales auxquels font face les institutions financières qui empêchent/ yy Existe-t-il actuellement des partenariats public–privé limitent les prêts au secteur privé de la santé ? mis en place avec des entités du secteur privé qui se focalisent sur la planification familiale, la santé mater- nelle et infantile, l’innovation numérique ou mobile Ressources humaines pour la santé ou d’autres domaines ? yy Quel est le profil des prestataires de sante privés dans le pays (y compris les docteurs, gynécologues obstétric- yy Les investissements sociaux actuels des entreprises en iens, médecins généralistes, infirmiers, sages-femmes, RDC sont-ils liés à la pénétration et au développement pharmaciens, soigneurs traditionnels et autres) ? de nouveaux marchés ? Comment se perçoivent-ils en tant que partie prenante dans le système de santé de yy Quels sont les besoins en termes de ressources la RDC ? humaines dans le secteur privé de la santé ? yy Quelles sont les structures qui contribuent à la for- Prestation de services mation des prestataires du secteur privé (initiale et yy Quelles sont les lacunes du secteur public que le continu) et quel est le processus d’accréditation pour secteur prive remplit en matière de prestation de ces structures ? services et/ou distribution/vente de produits ? yy Quels sont les facteurs qui affectent la provision de Information produits et services par le secteur privé en matière yy Quelles sont les contraintes clés qui limitent les con- de planification familiale, santé maternelle et infan- tributions du secteur privé au système d’information tile, et autres domaines de la santé ? sanitaire ? yy Quelles sont les contraintes à l’augmentation de la yy Veuillez décrire vos initiatives mobiles ou numériques demande et de l’utilisation de produits et services du pour la santé. Avez-vous utilisé l’argent mobile pour secteur privé ? les activités de santé ? 106 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O ANNEX B. KEY STAKEHOLDER LIST The assessment field team met with the following stakeholders by city. Bukavu Implementing Partner American Refugee Committee—ASILI Project Private Sector (FBO) BDOM Private Sector (FBO) Hôpital Général de Référence Dr. Rau-Ciriri Private Sector (FBO) Hospital/Foundation PANZI and 8eme CEPAK Private Sector (For-Profit) Pharmakina Private Sector (For-Profit) Skyborn Hospital Public Sector Division Provinciale de la Santé (DPS) Goma Implementing Partner Cordaid Implementing Partner Medecins Sans Frontieres Holland Implementing Partner Save the Children Implementing Partner UNICEF Private Sector (FBO) Charité Maternelle Hospital Private Sector (FBO) Hôpital de Kyeshero Private Sector (For-Profit) CIMAK Hospital Private Sector (NGO/Nonprofit) ASRAMES Private Sector (NGO/Nonprofit) Heal Africa Public Sector Division Provinciale de la Santé (DPS) Kinshasa Civil Society Alliance du Secteur Privé de la Santé (ASPS) Civil Society Centre de Gestion de Risque et d’Accompagnement Technique des Mutuels de Santé (CGAT) Civil Society Association Professionnelle des Coopératives d’Épargne et Crédit (APCEC) Civil Society Mouvement Ouvrier Chrétien du Congo (MOCC) Civil Society Plateforme des Organisations Promotrices des Mutuelles de Santé du Congo (POMUCO) Civil Society Order of Doctors Civil Society Societe Congolaise de la Practice de Sages-Femmes (SCOSAF) Civil Society Order of Pharmacists Corporate Fédération des Entreprises du Congo (FEC) Corporate AIB RDC Corporate Global Access Health Network (GAHN) Corporate iFinance Corporate ProCredit Bank Corporate Trust Merchant Bank (TMB) Corporate Africell Corporate Airtel Corporate Orange Corporate Vodacom Corporate WapiMed Corporate Essor Equipment Donor USAID (continues on page 108) AP P E NDIC E S 107 Donor Department for International Development Donor European Union Donor GAVI Donor World Bank Donor International Finance Corporation (IFC) Implementing Partner JSI—Maternal and Child Survival Program Implementing Partner UNICEF Implementing Partner Engenderhealth Implementing Partner FINCA Implementing Partner FHI 360 Implementing Partner MSH Implementing Partner World Health Organization (WHO) Implementing Partner Abt Associates—Health Financing and Governance (HFG) Project Implementing Partner Pathfinder Implementing Partner DKT Implementing Partner PSI Implementing Partner Save the Children Implementing Partner Tulane University Implementing Partner UNFPA Private Sector (FBO) IMA World Health Private Sector (FBO) Eglise du Christ au Congo (ECC) Private Sector (FBO) BDOM Kinshasa Private Sector (FBO) SANRU Private Sector (FBO) Armee du Salut Private Sector (FBO) Kimbanguist Church Private Sector (FBO) Caritas Private Sector (FBO) Union des Mutuelles de Santé du Congo (UMUSAC) Private Sector (FBO) Centre Bandal Private Sector (For-Profit—IPPF Affiliate) Clinique Bongisa Libota Private Sector (For-Profit) Clinique de la Nuit Private Sector (For-Profit) Clinique IK Private Sector (For-Profit) Clinique Marie Yvette Private Sector (For-Profit) MissionPharma Private Sector (For-Profit) Pharmagros Private Sector (For-Profit) Phatkin Private Sector (NGO/Nonprofit) Mutuelle de Santé des Enseignants de l’Enseignement Primaire, Secondaire et Professionnel (EPSP) Private Sector (NGO/Nonprofit) Solidarco Private Sector (NGO/Nonprofit) Fédération des Centrales d’Approvisionnement en Médicaments Essentiels (FEDECAME) Private Sector (NGO/Nonprofit) CAMESKIN Private Sector (NGO/Nonprofit) Association de Santé Familiale (ASF) Public Sector Programme National de Lutte contre les Infections Respiratoires Aiguës (PNIRA) Public Sector Coordinator of the Prise en Charge Intégrée des Maladies de l’Enfant (PCIME) Public Sector Programme National de Lutte contre les Maladies Diarrhéiques (PNLMD) Public Sector Programme Nationale de Nutrition (PRONAUT) 108 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Public Sector Direction de Partenariat, MSP Public Sector Conseiller en Charge du Secteur Privé—MSP Public Sector Program Nationale de l’Appui de la Protection Sociale (PNAPS) Public Sector Autorité de Régulation et de Contrôle des Assurances (ARCA) Public Sector Programme National de Promotion des Mutuelles de Santé (PNPMS) Public Sector Direction de la Lutte contre les Maladies—MSP Public Sector Programme National de Lutte contre le Paludisme (PNLP)—MSP Public Sector Programme National de Santé pour Adolescents (PNSA)—MSP Public Sector Programme National de Santé de la Reproduction (PNSR)—MSP Public Sector Directeur de Cabinet—MSP Public Sector Direction de Développement de Soins de Santé Primaires—MSP Public Sector Division de SNIS, Direction de Développement de Soins de Santé Primaires—MSP Public Sector Direction d’études et de planification (DEP) Public Sector Office Congolais du Contrôle (OCC) Public Sector Programme National d’Approvisionnement en Médicament (PNAM) Public Sector Direction de la Formation Continue—MSP Civil Society Association of Midwives Civil Society Order of Nurses Public Sector Direction des Services Généraux et des Ressources Humaines—MSP Public Sector Direction de l’Enseignement des Sciences de la Santé—MSP Lubumbashi Private Sector (NGO/Nonprofit) Association de Bien-Être Familial–Naissances Désirées (ABEF-ND) Private Sector (FBO) Agence Adventiste d’Aide et Développement (ADRA) Private Sector (For-Profit) Centre Médical du Centre-Ville (CMDC) Private Sector (For-Profit, Enterprise Centre Médical de la Communauté Affiliated) Private Sector (For-Profit) Centre Médical Light Public Sector Division Provinciale de la Santé (DPS) Private Sector (FBO) Clinique Les Meles Private Sector (FBO—ABEF Affiliate) Clinique Masaidijano Private Sector (For-Profit) Clinique St. Felly Private Sector (NGO/Nonprofit) Clinique Watoto Implementing Partner Concern Implementing Partner Catholic Relief Services (CRS) Private Sector (NGO/Nonprofit) Fondation Vie et Sante, Centre de Chirurgie et Traumatologie (Clinique Del Gado) Private Sector (FBO) Centre de Santé de St François d’Assise Private Sector (FBO—Armée du Salut Compassion Clinic Associate) Private Sector (NGO/Nonprofit) Centre de Santé Kalebuka Private Sector (NGO—ABEF Clinic) Centre de Santé de Uzazi Bora Public Sector Zone de Santé de Kamalondo Implementing Partner Catholic Relief Services (CRS)–ELIKIA Project Corporate LISUNGI Corporate Standard Bank (continues on page 108) AP P E NDIC E S 109 Implementing Partner Abt Associates—Health Financing and Governance (HFG) Project Public Sector Hôpital Sendwe Private Sector (NGO/Nonprofit) Hôpital Barak—NGO Arc en Ciel Private Sector (NGO/Nonprofit) Hôpital Radem Hewabora—NGO Radem Corporate Investment Durable de Katanga (IDAK) Implementing Partner International Rescue Committee Corporate Katanga Mining Company Implementing Partner MEASURE Evaluation Public Sector Chef de Province Corporate MMG Implementing Partner MSH Implementing Partner Pathfinder Civil Society Order of Doctors Civil Society Order of Pharmacists Private Sector (For-Profit) Etisalat Pharmacy Private Sector (NGO/Nonprofit) Polyclinique Les Mels Private Sector (NGO/Nonprofit) Polyclinique Medicare Civil Society Plateforme des Organisations de la Société Civile Intervenant dans le Secteur Minier (POM) Public Sector Ministère Provincial Private Sector (NGO/Nonprofit) CAMELU Private Sector (For-Profit) Unique Private Sector (NGO/Nonprofit) Association de Santé Familiale (ASF) Civil Society Syndicat National des Médecins du Congo (SYNAMED) Corporate Kamoto Mining Company Matadi Public Sector Division Provinciale de la Santé (DPS) Civil Society Order of Doctors Private Sector (NGO/Nonprofit) Centrale d’Achats et d’Approvisionnement en Médicaments Essentiels au Bas-Congo Ouest (CAAMEBO) Private Sector (FBO) Hôpital Saint Gérard Congrégation des Pères Rédemption Kolwezi Civil Society Syndicat National des Médecins du Congo (SYNAMED) Private Sector Hôpital Général de Mwangeji Civil Society Order of Doctors Private Sector (For-Profit—Corporate) Hôpital Général de Référence de GECAMINE Civil Society Syndicat des Infirmiers et Infirmieres Civil Society Order of Pharmacists Private Sector (FBO) Polyclinique Adventisse Private Sector (For-Profit—Corporate) Centre de Santé de l’Entreprise Minière Komoto Copper Compagny SA Corporate Komoto Copper Compagny SA Private Sector (For-Profit—Corporate) Centre de Santé de l’Entreprise Minière de la Société Minière de Tenke Fungurume (SMTF) Corporate Société Minière de Tenke Fungurume (SMTF) Private Sector (FBO) Hôpital Méthodiste Mama Tabitha 110 T H E ROLE OF T H E P RI VATE S ECTO R I N I MPROVI N G TH E PE R FORMANCE OF THE HE ALTH SYSTE M IN THE DE MOCRATIC RE PUBL I C OF C ONG O Mbuji-Mayi Private Sector (For-Profit) Pharmacy Sapaumed Private Sector (For-Profit) Pharma KM Private Sector (For-Profit) Milo Pharma Corporate Advans Bank Public Sector Division Provinciale de la Santé (DPS) Public Sector Provincial Ministry of Health Private Sector (FBO) Hôpital Christ Roi Public Sector/Private Sector (FBO) Hôpital Kansele Private Sector (FBO) Hôpital Presbytérien de Dibindi Private Sector (For-Profit) Hôpital Valentin Disashi Private Sector (For-Profit) Pharmacie Sanctuaire Private Sector Université Officielle de Mbuji Mayi (UOM) Private Sector (For-Profit) Centre Hospitalier Saint Sauveur Private Sector (For-Profit) Centre Hospitalier Pédiatrique de Mbuji Mayi (CHPM) Private Sector (NGO/Nonprofit) Centre de Distribution Régionale CADMEKO Civil Society Order of Doctors Implementing Partner Save the Children Private Sector (Corporate) MIBA (Société Minière de Bakwanga) Public Sector Office Congolais de Contrôle Private Sector (FBO) CSR Bakhita Implementing Partner Caritas Private Sector (For-Profit) Pharmacy Beldis Private Sector (For-Profit) Pharmacy Hewa Nzuri Civil Society Order of Pharmacists Private Sector (For-Profit) Centre Hospitalier Notre Dame Other Implementing Partner Training for Health Equity Network (THENet) Implementing Partner 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