The operational budget cost for a full-fledged normative HSSS health district, with 10 health centres and 1 district hospital, is thus $17.91/inhabitant/year. This HSSS health district offers a comprehensive essential health services package (Minimum and Complementary Package of Activities) including maternal, neonatal, and child health care; reproductive health services; surgery care; internal medicine and chronic care; tuberculosis, HIV/AIDS, and malaria care; communicable disease care; preventive medical services; management and maintenance services; etc. The HSSS health district is assumed to have a functioning referral system, that is, there is little overlap of health services between the health centre and the district hospital level.
Practical benefit of the resource planning work (grouped according to objectives of this exercise):
Exercise objective 1: To inform the policy dialogue on affordability of the HSSS essential health services package to be provided at district level
The Ministry of Health employed the normative HSSS district resource planning results in 4 ways linked to the policy dialogue on affordability of the HSSS:
1.
Advocacy and negotiation instrument
2.
Instrument to align donors
1.
Advocacy and negotiation instrument: to advocate and negotiate for more funding for the (decentralized) health districts
Negotiations with the Ministry of Finance were better informed by the DR Congo costing database. The government health budget was elaborated based on the normative model health district and the costing results obtained from this exercise. In the past, costing and budgeting were usually based on the previous year’s estimations, without an updated analysis of health sector needs.
DR Congo submitted a successful proposal for the Global Fund - Health Systems Strengthening window, 9
th
Round. The normative model health district planning results served as a point of reference to propose channeling 9th Round funds to the health district as a unit as opposed to specific projects or programs. This was possible because the planning and costing work itself was done for the district level, integrating all services at that level, including management and prevention.
The comprehensive resource budget for a normative model district allowed the MoH to better negotiate with donors based on transparent information: by demonstrating a solid list of interventions, resources, and associated budget needs for a defined health package, the MoH found donors much more willing to consider country planning interests.
2.
Instrument to align donors: to channel existing resources towards the health district level
Large proportions of donor funds in the DR Congo have traditionally gone to management and administration of programs -- for example, up to 40% of the
European Development Fund (
EDF)’
s 9
th
Program for Health in DR Congo was spent on management and administration [
9]. By demonstrating that the actual budget needs for operating a well-functioning health district based on the HSSS in DR Congo was higher than donors had planned for, the MoH was able to make the case that more funds need to be channeled to the field, i.e., to district health level, rather than into administration and overhead.
The
European Development Fund (
EDF)’
s 10
th
Program for Health in DR Congo was planned and drafted with the inclusion of the MoH resource planning team for key planning and budgeting activities [
10]. The budget of the
10
th
Program for Health is €51 million; the initial EDF plan was to cover 100 health districts with this amount. The MoH strongly advocated for and successfully negotiated a reduction in the number of districts covered to 20-25, based on the results of the normative model health district planning exercise which demonstrated the need for a total operating budget of at least $17.91/inhabitant/year to adequately run a health district providing good quality services.
DR Congo drafted a new national health plan in 2011 (
Plan national du développement sanitaire 2011-2015), which is aligned to the Poverty Reduction Strategy Paper (PRSP). One of the principal focus areas of the new plan is to support and strengthen the health district. The MoH’s discussions with international partners on the affordability and budget accorded to districts were based on the normative health district resource planning results. The Medium-Term Expenditure Framework (MTEF) for the new health plan drew heavily from the costing database.
3.
Field planning: to assist MoH, NGOs and donors in the provinces (field) to plan their district health services
In 2009/10, in order to better assess health facility needs in districts, the MoH resource planning team collaborated with an international NGO in 2 pilot districts by calculating a detailed resource base and budget needs for current actual health service provision and quality; they analyzed the gap between the current, low-quality `reality’ scenario and the normative model health district target of the MoH. This collaborative work resulted in an updated equipment inventory in these 2 districts, budget provisions for a better supply of drugs and consumable items, and a debate on a new human resource plan. For the MoH, this collaboration with a development partner has demonstrated a practical example of normalizing health service provision and quality across districts which have varying levels of service quality, donor support, and history.
In 2013, the same exercise as presented above was undertaken in 2 health centres and 1 district hospital in another province by a bilateral agency, in close collaboration with the MoH and its resource planning team. This exercise is currently on-going but attests to the usefulness of doing a gap assessment based on the reality in health facilities vis - vis a modelled and costed norm.
An operating budget simulation was done for the newly-built Hôpital du Cinquentenaire, a national level tertiary care specialty hospital on the basis of the iHTP simulations done at the district hospital level. This budget forecast assisted in having a more concrete idea of the level of funds which need to be included in the Ministry of Health budget in order to run this specialized health facility.
A national-level assessment conducted in 2012 studied the required type, amount, and costs of medicines and health supplies for operationalization of the new national health plan (PNDS) [
11]. The costing database was used to conduct a separate sub-analysis of medicines and supplies and this was supplemented with additional data linked to the specific terms of reference of the assessment. The continued use of the costing database years after it was originally created demonstrates the high utility value of such data sets.
The district-level resource planning work is serving to feed into the cost analysis of the National Health Plan (
Plan National du Developpement Sanitaire) by providing input into the more strategic OneHealth [
12] costing exercise currently on-going in 2013.
Exercise objective 2: To provide an absolute minimum resource base and operational budget for the HSSS essential health services package to be provided at district level, which can be used as a normative model across districts
Based on these results, the normative model health district costs can be considered as an absolute minimum cost base for the essential health services package. A similar type of normative planning exercise was undertaken by a bilateral agency in one of the districts under their responsibility which was known to function well (Kenge) [
13]. Their results at health centre level was $4.20/inhabitant/year and at hospital level $10.20/inhabitant/year. Since these numbers did not include health district management and HIV, one can state that these numbers correspond very well to the MoH’s normative model basic health centre and district hospital costs. The bilateral agency exercise was done with a similar premise (normative) and context and thus at least partly validates, by comparison, the MoH’s results.
Congolese health districts are financed by a wide variety of donors, leading to varying services and utilization rates across districts. This resource planning exercise being HSSS-based and normative in nature, allows for a common resource base standard at which to aim across districts, so that bridging the financing gap becomes easier and more equitable. It thus serves as a realistic model to strive for in terms of functionality, resource usage, utilization, and interventions provided in a fully functioning DR Congo health district.
Exercise objective 3: To build capacity and establish sustainability of resource planning activities within the DR Congo Ministry of Health by ensuring ownership of the resource planning methodology
The Planning Directorate, MoH, invested heavily in building resource planning capacity. Three experts worked on the iHTP resource planning and costing database over 9 months to build up the original database with the MPA and CPA for the health district. This resource planning team also supported district management teams in district health planning, and collaborated with provincial and district health authorities in formulating their provincial and district health plans.
The resource planning team has thus fully adapted and embedded the global instrument of iHTP to the local DR Congo context via the planning and costing work for the HSSS normative district. The effort made to adapt the tool included WHO training and support to the MoH team for one year, corresponding to approximately 300 man-hours from international staff. The continued existence and deployment to the districts of the resource planning team is testimony to the MoH’s ownership of the iHTP resource planning methodology as well as the country’s long-term strategy to maintain planning capacity within its institutions.
Limitations to the study include the lack of available and reliable data, especially concerning utilization rates, case load, and other facility-based data. Another limitation was the fact that the iHTP tool was used to model non-clinical interventions (management of the district, for example) for which it was not initially conceived. The authors of this paper were conscious of these limitations and made best-guess estimations based on available data and mapped out iHTP non-clinical algorithms in a way which was most compatible with the tool structure.