Promoting universal access to health services in post-conflict situations : what role can large scale cash transfer programmes play for better outcomes ?

Making well-informed decisions about how best to achieve MDGs depends on the ability of public policy makers in accessing the best available evidence about what is known to work and what could be potential benefits, and ways to integrate solutions into complex and often under-resourced health systems. Conditional cash transfer programmes have been largely explored as a policy for improving the education and health outcomes of poor children in developing countries as well as a tool for long-term poverty alleviation; but needs to be appropriate to the context and both fiscally and politically affordable. In DRC, the crisis and conflicts of the past decades severely affected the health status of the population and degraded the health system. Consequently, efforts in reducing infant and under-five morbidity and mortality are seriously hampered by widespread poverty and economic deregulation. The aim of this paper is to question the feasibility and affordability of cash transfer compared to 2 alternatives: an outreach health and nutrition programme with a behavioral change communication component and the elimination of basic health care user fees. The results show that children health outcomes may instead be driven by the equal distribution of quality services through outreach health and nutrition programmes (20% to real GDP) than a large scale health-oriented conditional cash transfer (25.9% to real GDP). A number of issues is outlined with regard to the country's socio-economic and political context : (i) health-oriented conditional cash transfer cannot operate in DRC due to supply-side constraints and lack of health supply strategy, logistics and engineering ; (ii) targeting is somewhat time consuming and irrelevant in such context with a headcount averaging 77% ; (iii) outcomes of a geographic focused cash transfer programme could be expected on improvement of nutritional status, but less on the rise of health demand and would be difficult to scale-up.