Sylvain Nkwenkeu , CREPPEM University of Grenoble

1. Promoting universal access to health services in post-conflict situations: what role can large scale cash transfer programmes play for better outcomes? Sylvain Nkwenkeu, CREPPEMUniversity of Grenoble

2. Large differences in health outcomes between different socio-economic groups and regions : while 52% of U5 in rural areas were chronically-malnourished (stunted) in 2007, prevalence was 36% in urban areas. The situation is still unstable and volatile, conducive to deterioration in the quality of health services and grave inequity in access to basic social services. For health-related MDGs, the Country is still struggling to reach the pre-1990 levels Context and rationale: the DRC case

3. DRC: isthere a correlationbetweenunderweight and U5 mortality? U5 mortality Underweight

4. Problemanalysis • 77% of the children in the country live below the poverty line (0.72 US$/day) • The domestic demand of health services (health service utilization) was hampered : as a result, morbidity and mortality remain high • Underweight (%, mod & severe) : 24.2 / 45.5 • Under-five mortality rate (U5MR) of 148 out of 1,000 live births • The health system is more focused on the medical model, and obscures the determinants of community health • The government welfare mechanism is focused on employment, excluding the most needy (poorest, unemployed and rurals). • 60-70% of the population lost their livelihoods mainly focused on agriculture (capabilities for a minimal functioning) • There is a need for human capital accumulation to increase the ability of the community to produce, improve child and infant nutrition and therefore reduce child morbidity and mortality *DHS 2007, unless otherwise stated

5. Problemanalysis Amount allocated per capita to health care and education from 2004 to 2008 (U.S. $) DRC expenditure by sector from 2006 and 2008 (in million US$)* *Source: Based on empirical calculations of data communicated by the Direction of Preparation and Follow up of the Budget, Ministry of Budget, 6 February 2009 (Exchange rate based on the UN rates)

6. Impact of the abolition of user fee on HCU Source, UNICEF, 2004

7. Towards the MDGs: the CAF as an innovativetool

8. Policy options Main option: Child-Focused (U5) Universal Cash Transfers with a health-oriented conditionality might be the best way to reduce malnutrition and U5 mortalityatomeet 2 objectives: • one that offsets the income effect of the shock directly through cash transfers; and ; • one that seeks to mitigate its consequences on human development outcomes such as nutrition status of children and help to scale-up the community-based nutrition programme. Alternative option 1:an outreach health and nutrition programme with a behavioural change communication component (therapeutic feeding centers, nutrition education for mothers, provision of vitamin A supplements and deworming: a possible reduction of administrative cost). Alternative option 2:the abolition of basic health care user fees

9. Methods • 1-2-3 Survey data, MTEF 2010. • Costing exercise : US $ 10/child/month for the least interesting scenario and US $ 15/child/month for the better one, the direct costs of the transfer (amount of cash to cover food and non-food needs for a child per month below the national poverty line ($ 0.72 per person per day). • 12% for administrative cost to deliver the programs and 25% leakages • The costs of alternatives have been calculated as per public expenditure rather than budget allocations. • Cost-benefit analysis of CCT and determine whether it is economical and cost-effective in order to reduce poverty and accumulate human capital

10. Results and discussion Universal or targeted programme? The dilemma • Several vulnerable groups do exist: street children, abused children, children separated from their parents, children in conflict with the law, exploited children, refugee children, disabled children, etc. • It is possible for a child to be both disabled and on the street or on the street and abused, etc. • It is therefore difficult to project a reduction of child poverty and vulnerability by acting exclusively on family structures as it is the case in Latin American countries (ref. PROGRESA). • This complicates any targeting as OVCs living outside a structured household will not be affected by the CCT even though they culminate worst poverty and vulnerability.

11. * National poverty line actually rank at US$ 0.72 per person per day; ** 2010 real GDP as per national MTEF

12. Policies alternatives and costs * The distribution of nutritional supplements is now integrated with Vit A and deworming ** From the Health Sector MTEF, and does not take into account leakages (normally low)

13. The estimated annual requirements to develop and support health services as planned in the MTEF are in the range of US$ 430 million, around US$ 6.50 per capita annually, a level of public spending on health care that would be consistent with countries with an annual GDP per capita of US$ 200. • It suggests an exponential increase in resource levels and requires annual public spending of US$ 16 to US$ 22 per capita, rising to US$ 30 to US$ 40. • By this standard, current estimated total domestic and international public spending of around US$ 5 to US$ 6 in DRC implies a minimum annual gap of US$ 10 per capita, or US$ 600 million additional required resources. • The deterioration of the macroeconomic balances and the dollarization of the economy are seriously jeopardizing the ability of the government to use the traditional monetary instruments, translating any domestic borrowing immediately to inflation and exchange rate depreciation. • Potential availability of funding is therefore not enough to ensure the successful introduction of CCT as a national programme. This also requires a favourable political and social climate, with proponents who will advocate for the necessary share of the budget.

14. User fees and drug costs raise significant barriers to access to care for the poor, and one of the aims of domestic and international public financing is to substitute for the current level of out-of-pocket payments in order to improve access for the poor. • Given the budget execution record described previously, even this level of spending is unlikely to be achieved. • .

15. Concludingremarks • CCT cannot operate in areas like DRC with supply-side constraints without a comprehensive health supply strategy • In a context of generalized poverty (headcount = 77%), targeting is time consuming and is irrelevant • The programme may be administratively affordable (low administrative cost) as it is relying on an existing community-based nutrition program • The outcomes could be expected on improvement of nutritional status, but less on the rise for health demand • The option might be cost effective, but difficult to be scale-up where there is no community-based nutrition program