Democratic Republic of Congo (DRC)

Project Information

Objective: The Health System Strengthening for Better Maternal and Child Health Results project seeks to improve the utilization as well as the quality of maternal and child health services in 140 health zones in 11 provinces (i.e. Mai-Ndombe, Kwilu, Kwango, Sud Ubangui, Tshuapa, Mongala, Equateur, Haut Katanga, Haut Lomami, Loualaba, and Maniema) targeting approximately 24 million people.
Status: Active
Date Effective: 05/31/2016 to 12/31/3019
Financing: HRITF $6.5 million and IDA $220 million
Other Financial Contributions: N/A

Photo credit: World Bank/Martine Perret

PROJECT RATIONALE                 

In recent years, the Democratic Republic of Congo has made considerable progress in reducing the under-five mortality rate from 148 deaths per 1,000 live births in 2007 to 104 deaths in 2013. Despite this reduction, the maternal mortality ratio remains high at 846 deaths per 100,000 live births, and other Maternal and Child Health (MCH) indicators continue to perform poorly with, for example, a contraceptive prevalence rate stagnating at 20 percent since 2008 and chronic malnutrition among children under five persisting at 43 percent. On the supply-side, this poor performance is directly correlated with low quality of care, inadequate preparedness for obstetric emergencies, and the limited availability of effective referral systems. On the demand-side, MCH results are adversely affected by poor access to facilities, socio-cultural impediments, and financial barriers. MCH performance is further compounded by economic and geographic disparities. For example, only 36 percent of children in the poorest wealth quintile are immunized compared to 65 percent in the richest wealth quintile (DHS, 2013–2014).


PBF Payments

The Performance-Based Financing (PBF) component specifically aims to support the delivery of a basic and complementary package of priority Maternal and Child Health (MCH) services. A provincial purchasing agencies – contracted by the Ministry of Public Health – incentivizes public and private health centers and first level hospitals to increase MCH service coverage and enhance the quality of care.  PBF payments are made quarterly by these provincial purchasing agencies upon the verification of achieved results.  

In addition, performance frameworks are established to improve the governance, coaching, and accountability of health administrations at all levels of the health system.  Single contracts are created to support a single budgeting and planning exercise, a single monitoring and evaluation process, and a single reporting mechanism. These single contracts are complemented by the performance framework which looks at the quality and efficiency of the services provided by the health administration. PBF payments are made quarterly based on verification of the results achieved.

Conversely, Health System Strengthening for Better Maternal and Child Health Results project includes a community PBF scheme aimed at strengthening the relationship between communities and health facilities, further stimulating demand. It builds on networks of community relays – elected at village level and forming Health Area Development Committees (CODESA) – contracted and incentivized by Health Zone Supervisory Teams to promote and monitor MCH through household visits. Under this demand-side scheme, PBF incentives are disbursed quarterly and can be used to (i) support the operations of the CODESA, (ii) incentivize CODESA members to provide community service, and (iii) subsidize community health projects.. Overall, the implementation of PBF activities is regulated by the Ministry of Public Health, which ensures compliance with PBF objectives and principles and alignment with national health promotion norms and guidelines at central, provincial and operational levels.


Under the supply-side PBF scheme, the quantity of services delivered is verified quarterly by the provincial purchasing agency using facility registers. The technical quality of care is also assessed quarterly by Health Zone Supervisory Teams and Provincial Health Divisions respectively administering a quality checklist in health centers and in hospitals though the use of tablets to render the verification of quality more efficient and obtain just in time data.  At community level, local associations are contracted to carry out home visits and ascertain that reported services have been delivered to patients. This community verification also measures user satisfaction. In addition, the supply-side PBF scheme also involves a counter-verification whereby an external agency is contracted to verify results ex-ante and ex-post.  

Under the demand-side PBF scheme, Health Zone Supervisory Teams ascertain that households have been visited as reported and local associations ensure that the community is satisfied with the services provided at community level.


Status and achievements – Fiscal Year 2016

The Health System Strengthening for Better Maternal and Child Health Results project builds on the results and lessons learned from PBF experiences across the region. Its design was also informed by the implementation and impact evaluation of a PBF pilot in the health district of Haut-Katanga (2010-2014). These experiences helped refine and restructure the PBF scheme in DRC, enabling a successful scale up from eight to 140 health zones.

Due to delays in parliamentary approval, the Health System Strengthening for Better Maternal and Child Health Results project only became effective on May 30, 2016.  To date, the following activities were carried out:

  1. Development and validation of the Performance Based Financing (PBF) operational manual of the Ministry of Health (manual developed in collaboration with the World Bank, UNICEF, GAVI, Global Fund, USAID and UNFPA);
  2. Establishment of Public Utility Institutions (EUP) which will serve as the purchasing and recruiting agency for PBF;
  3. Training of EUP administrative staff;
  4. Training of 150 verifiers contracted by the EUP to verify the quantity and quality of services provided;
  5. Completion of 11 provincial workshops to support contracting and strategic purchasing; and
  6. Training of health facilities in Bandundu to be followed by Equateur, Maniema and Katanga.

In addition, an advanced Information and Communication Technologies (ICT) is currently being developed. It will include an upgraded web-enabled application, tablet and smart phone-based software for data verification, quality checklist data entry, vignettes and community client satisfaction surveys are being tested for scaling up.

The project is implemented in close partnership with the Global Fund to Fight AIDS, Tuberculosis and Malaria, GAVI, UNICEF, USAID, and UNFPA. It is financed through a virtual basket of funds which fosters increased collaboration, greater alignment and better harmonization among development partners.

Lessons Learned

The implementation of the previous Health System Strengthening for Better Maternal and Child Health (2014) as well as initially expanding PBF to 140 health zones generated several lessons. One of these lessons involves building on local capacity to ensure the technical and financial sustainability of the project and foster in-country ownership. Another lesson involves ensuring sufficient funding for the PBF package of services and providing sufficient technical and financial oversight to support project implementation, especially during the two years.


The impact evaluation is designed to assess (a) the effects of PBF on the quantity and the quality of services; (b) the differential impact of different quality payment methods on the quality of care (i.e. structural measures versus process measures; paying for knowledge through vignettes), and (c) the impact of various community engagement approaches inherent to the PBF component and aimed at improving nutrition, community behavior and health service utilization. The impact evaluation will involve randomly selected health zones and control health zones located in the same Provinces.