CENTRAL AFRICAN REPUBLIC Public Expenditure Review in Key Human Development Sectors September 2023 1 CENTRAL AFRICAN REPUBLIC Public Expenditure Review in Key Human Development Sectors 2 3 TABLE OF CONTENTS ACKNOWLEDGEMENTS...............................................................................................................................6 CHAPTER 5. HEALTH.................................................................................................................................. 97 5.1. Introduction....................................................................................................................................................................................98 ABBREVIATIONS............................................................................................................................................ 7 5.1. Overview of the Health Sector in CAR Including Existing Government Health Policies, Plans, and Strategies.................................................................................................................................................................................................98 CHAPTER 1. INTRODUCTION.....................................................................................................................11 5.2. Structure and Organization of the Health Sector.....................................................................................................99 References................................................................................................................................................................................................ 17 5.3. Trends and Status in Health Inputs and Outcomes in CAR.............................................................................. 100 5.4. Trend, Sources, and Composition of Total Health Expenditures in CAR..................................................... 107 CHAPTER 2. MACRO/FISCAL....................................................................................................................19 2.1. Background......................................................................................................................................................................................20 5.5. Equity in access to health services and financial protection...........................................................................120 2.2. Recent Macroeconomic Trends and Fiscal Policy.....................................................................................................20 5.6. Implications of COVID-19 for Health Financing in CAR........................................................................................124 2.3. Conclusions and Recommendations ...............................................................................................................................30 5.7. Overview of Results Based Financing in the Health Sector in CAR................................................................127 References................................................................................................................................................................................................33 5.8. Recommendations................................................................................................................................................................... 129 References.............................................................................................................................................................................................. 131 CHAPTER 3. PUBLIC FINANCIAL MANAGEMENT............................................................................ 35 3.1. Introduction.................................................................................................................................................................................... 36 CHAPTER 6. SOCIAL PROTECTION.......................................................................................................133 3.2. Recent History of Public Financial Management Reforms..................................................................................37 6.1. Introduction...................................................................................................................................................................................134 3.3. Decentralization, Deconcentration, and Public Financial Management..................................................... 38 6.2. Overview of Management and Institutional Context of the Social Protection Sector...................... 136 3.4. Budget Preparation, Approval, and Evaluation.......................................................................................................... 38 6.3. Public Expenditure on Social Protection...................................................................................................................... 141 3.5. Budget Execution Performance 2017–20...................................................................................................................... 39 6.4. Recommendations ...................................................................................................................................................................154 3.6. Core Public Financial Management Systems...............................................................................................................42 References..............................................................................................................................................................................................157 3.7. Recommendations...................................................................................................................................................................... 48 APPENDIXES ............................................................................................................................................. 159 References................................................................................................................................................................................................ 51 A1. Education........................................................................................................................................................................................160 A2. Social Protection........................................................................................................................................................................ 185 CHAPTER 4. EDUCATION.......................................................................................................................... 53 4.1. Introduction.................................................................................................................................................................................... 54 A3. Health...............................................................................................................................................................................................190 4.2. Overview of the Education System................................................................................................................................... 54 REFERENCES............................................................................................................................................. 208 4.3. Education Sector Financing ................................................................................................................................................. 62 4.4. Human Resource Management...........................................................................................................................................73 4.5. Financing Needs and Sustainability of Public Spending on Education........................................................ 84 4.6. Recommendations.....................................................................................................................................................................89 4 References............................................................................................................................................................................................... 95 5 ABBREVIATIONS ACCT - Central Treasury Accounting Agency [Agence DALYs - Disability-adjusted life years Comptable Centrale du Trésor] DGBS - General of Scholarships and Internships ACS - Agents and civil servants DGESP - General Directorate for Studies, Statistics, and AF - Additional financing Planning [Direction générale des études, des statistiques et AFD - Agence Française de Développement de la planification] AGETIP-CAF - CAR Agency for the Execution of Works of DGMP - General Directorate for Procurement [Direction Public Interest Générale des Marchés Publics] AGIR - Public Expenditure and Investment Management DH - District Hospital Reform Project [Projet d’Appui à la Gestion de Dépenses et DPMP - Directorate of Procurement Management Policy Investissements et aux Reformes] DPF - Development Policy Financing ACKNOWLEDGEMENTS AGR - Income generating activities [Activité Génératrices de Revenus] DRG - Diagnostic related group DRM - Domestic resource mobilization APPR - Agreement for Peace and Reconciliation EBESP - Emergency Basic Education Support Project ARMP - Public Procurement Regulatory Agency [Autorité de régulation des marchés publics] ECCD - Early Childhood Care and Development ARI - Acute respiratory infections ECF - Extended Credit Facility BMA - Bangui Metropolitan Area EGRA - Early Grade Reading Assessment CAR - Central African Republic EMIS - Education Management Information System This report has been prepared by a team led by Yevgeniya Savchenko. The team included (in alphabetical order) Ayesha Khan Kaiser, Boubakar Lompo, CEART - Committee of Experts on the Application of the ENAM - National Administrative and Justice School [Ecole Recommendations concerning Teaching Nationale d’Administration et de Magistrature] Cristelle Kouame, Elysée Aristide Houndetoungan, Frieda Vandeninden, Marianne Caballero Parra, Pierre-Emmanuel Couralet, Soazic Elise Wang CEM - Mutual Commitment Framework [Cadre ENI - Training college [Ecole Normale des Instituteurs] Sonne, and Tomi Diderot. The report was prepared under the guidance of d’Engagement Mutuel] ENMC - National Communal Monography Survey [Enquête Han Fraeters, Abdoulaye Seck, Halil Dundar, Magnus Lindelow, Iffath Sharif, CEMAC - Economic and Monetary Community of Central Nationale sur les Monographies Communales] Francisco Carneiro, Manuel Vargas, Carine Clert, and Clelia Rontoyanni. The Africa ENS - training college for secondary teachers and education team received invaluable advice and support from Nathalie Lahire, Philippe CFA - Compulsory financing arrangements managers [Ecole Normale Supérieure] Auffret, Paola Cerutti, Mahoko Kamatsuchi, Driss Zine Eddine, Avril Kaplan, EPSR - Emergency Public Services Response CFAF - CFA francs Gervais Yama, Wilfried Kouame, Oula Coulibaly, Maud Kouadio, Zoé Allier- CHI - Compulsory health insurance ESP - Education Sector Plan Gagneur and Oulimata Ndiaye. The team would also like to thank the peer reviewers Elena Georgieva-Andonovska, Melissa Adelman, Ellen Van De Poel, CHW - Community health workers ESPSP - Education Sector Policy Support Programme Boban Varghese Paul, Volkan Cetinkaya and Yasuhiko Matsuda for their very CIFS - Inter-ministerial Unit for SSN Coordination [Cellule ETAPE - Temporary classrooms [Espaces temporaires valuable insights. The team was supported by Arsene Gassy Djamba, Elif Interministérielle de Coordination des Filets Sociaux] d’apprentissage et de protection de l’enfant] Yukseker, Inass Ayoub– program assistants. In addition, the team greatly EU - European Union CKD - Chronic kidney disease benefited from consultations with key policymakers and analysts in CAR, FCV - Fragile, conflict, and violence CNSS - National Fund for Social Security [Caisse Nationale including officials from the Ministry of Economy, Plan and Cooperation; de Securité Sociale] GBV - Gender-based violence the Ministry of Finance and Budget; the Central African Republic Institute of Statistics and Economic and Social Studies; the Ministries in charge of COFOG - Classification of the Functions of Government GBD - Global Burden of Disease Education; the Ministry of Health; and the Bank of Central African States. CPR - Teacher training center [Centres Pédagogiques GDP - Gross domestic product Michael Alwan edited the report, Valerie Molina translated it into French, Régionaux] GER - Gross enrollment rate Sarah Alameddine led its graphic design, and Odilia Hebga provided CRD - Committee for the Management of Complaints GGE - General government expenditures communications support. [Comité de Règlement des Différends] GHE - Government health expenditure CT - Cash-transfer GoCAR - The Government of CAR 6 7 GPE - Global Partnership for Education MPSE - Ministry of Primary and Secondary Education PACAD - Support to Communities Affected by Displacement SPMPs - Deconcentrated service agencies [Services de HCI - Human Capital Index MEPSTA - Ministère de l’Enseignement Primaire Secondaire PAM - UN World Food Program [Programme Alimentaire Passation des Marchés Publics] HER - Higher education and research Technique et de l’Alphabétisation (former name of MEPS) Mondial] SSA - Sub-Saharan Africa HeRAMS - Health Resources and Services Availability MES - Ministry of Higher Education PARET - Return and Reintegration Support Project in the SSN - Social safety net Monitoring System MFB - Ministry of Finance and Budget Central African Republic STI - Sexually transmitted infection HG - History and geography MHE - Ministry of Higher Education PBF - Performance-Based Financing STR - Student-teacher ratios HP - Health posts MICS - Multi Indicator Cluster Surveys PER - Public Expenditure Review TB - Tuberculosis HR - Human resources MINUSCA - United Nations Multidimensional Integrated PFM - Public financial management TFP - Technical and financial partners HRMIS - Human Resource Management Information Stabilization Mission in the Central African Republic PIM - Public investment management TVET - Technical vocational education and training System MMR - Maternal mortality ratio PIMA - Public Investment Management Assessment UCAD - Cheikh Anta Diop University IBM - Iterative Beneficiary Monitoring MNCH - Maternal, neonatal, and child health PPA - Performance Purchasing Agency UCM - National medicine supply unit [Unité de Cessions des IA - School Inspectorate [Inspection Académique] MPFFPE - Ministry for the Advancement Women’s and PPP - Public-private partnerships Médicaments] ICASEES - National Institute of Statistics [Institut Children’s Affairs [Ministère de la Promotion de la Femme UIS - UNESCO Institute of Statistics RBF - Results Based Financing Centrafricain des Statistiques et des Etudes Economiques et de la Famille et de la Protection de l’Enfant] RCPCA - National Recovery and Peacebuilding Plan for UN - United Nations Sociales] MPSE - Ministry of Primary and Secondary Education the Central African Republic [Plan de Relèvement et de UNCTAD - United Nations Conference on Trade and ICT - Information and communication technology MSP - Ministry for Health and Population [Ministère chargé Consolidation de la Paix en République Centrafricaine] Development IDP - Internally displaced persons de la Santé et de la Population] RMET - Resource Mapping and Expenditure Tracking UNESCO - United Nations Educational, Scientific and IGF - General Inspectorate of Finance [Inspection Générale MSRTI - Ministry of Scientific Research and Technological Cultural Organization RMCH - Reproductive, Maternal, and Child Health des finances] Innovation RS - Health Regions [Régions Sanitaire] UNHCR - the United Nations High Commissioner for IHME - Institute of Health Metrics MTEL - Ministry of Technical Education and Literacy Refugees RUH - Regional University Hospitals IMCI - Integrated Management of Childhood Illness MTEPSFP - Ministry of Labor, Jobs and Social Protection UNICEF - United Nations Children’s Fund [Ministère du Travail, de l’Emploi et de la Protection Sociale SA - Social assistance IMF - International Monetary Fund et de la Formation Professionnelle] SARA - Service Availability and Readiness Assessment UNOPS - United Nations Office for Project Services LIC - Low-income country MTEFPS - Ministry of Labor, Employment, Training and Survey US - United States LIPW - Labor-intensive public works Social Protection [Ministère du Travail, de l’Emploi et de la SCR - Student-classroom ratio USAID - United States Agency for International Protection Sociale et de la Formation Professionnelle] Development LM - Labor market SD - Standard Deviation NCD - Non-communicable diseases VFA - Voluntary financing arrangements MAP - Minimum Activity Package SDG - Sustainable Development Goal NGO - nongovernmental organization WB - World Bank MAHRN - Ministry of Human Action and National SENI - Health Systems Strengthening Support Project Reconciliation [Ministère de l’Action Humanitaire et de la NHA - National Health Accounts WDI - World Development Indicators SHI - Social health insurance Réconciliation Nationale] OCHA - Office for the Coordination of Humanitarian Affairs WEO - World Economic Outlook SI - School inspectorates MASRN - Ministry of Social Affairs and National OECD - Organisation for Economic Co-operation and WHO - World Health Organization Reconciliation [Ministère des Affaires Sociales et de la SMNIA - Maternal, child, neonatal, and adolescent health Development Réconciliation Nationale] services YLD - Years lived with disabilities ODI - Overseas Development Institute METL - Ministry of Labour, Employment and Social SNETFP - National Strategy for Technical Education and YLL - Years of life lost Protection [Ministère du Travail, de l’Emploi et de la ONI - National Technology Office [Office National Vocational Training in the Central African Republic Protection Sociale] d’Informatique] SP - Social protection MEPC - Ministry of Economy, Planning, and Cooperation OOP - Out-of-pocket 8 9 CHAPTER 1. INTRODUCTION1 1  The authors of the introduction are Ayesha Khan Kaiser and Yevgeniya Savchenko. 10 11 The Central African Republic (CAR) is one of the poorest and most fragile countries in the world. Signs of positive CAR’s fragility explains its lower-than-expected Human Capital outcomes. At the root of the country’s conflicts economic growth and peacebuilding, evident since 2015, have since faltered in the face of a deteriorating security is the struggle between its political elites to pursue power and capture natural resources, undermining social environment and the COVID-19 pandemic. The Political Agreement for Peace and Reconciliation (APPR Accord), cohesion and capitalizing on local grievances to gain legitimacy (figure 1.1). The weak presence of the state and signed in February 2019 between the government and 14 armed groups and seen as a positive step toward building its security forces outside Bangui has contributed to a vicious cycle of fragility, which in turn affects the ability peace, did not hold. Post-December 2020 election unrest led to armed clashes that completely disrupted the of the government to provide adequate public services. CAR’s vast natural resource wealth and dependency, country, leading to a further deterioration in the humanitarian situation. Violence continued immediately after coupled with weak governance and management of the natural resource sector, are prevailing sources of fragility. the election on the outskirts of the capital of Bangui and in the North-West and Center of the country. By the Furthermore, the country’s porous borders and dependency on foreign security, humanitarian, and development end of May 2021, the government, with the support of allied troops from the Russian Federation and Rwanda, assistance make it prone to regional and international geopolitical tensions. These conditions are unconducive to had pushed back the rebels and reported that most of the country was under government control. The new stability, peace, and much-needed structural reforms for sustained growth and development (World Bank 2022). government was formed in June 2021. Human capital gaps in CAR are painfully evident in both health and education. Life expectancy remains the The country’s successive episodes of conflicts and violence have led to enormous challenges, and the second lowest worldwide, at 52.9 years in 2017 (World Bank 2019). CAR’s maternal mortality ratio (MMR) is one of humanitarian situation remains dire. Since gaining independence in 1960, CAR has not experienced a sustained the highest in the world with 829 deaths per 100,000 live births in 2017 (World Bank 2020a,b). Its Human Capital period of economic growth or peace. GDP per capita has dropped by almost half since independence, from US$620 Index (HCI) score places CAR below the fragile, conflict, and violence affected (FCV) countries’ average of 41 percent in 1961 to US$384 in 2019. Even though extreme poverty as a share of the population declined from 75.7 percent and Sub-Saharan African (SSA) countries’ average of 40 percent, and below its peers in the region (figure 1.2). in 2014 to 71.4 percent in 2019, it remains high compared to peer countries.2 Despite the high level of poverty, just over 20 percent of the population received a social security net (SSN) benefit in 2020; and the SSN consists mainly of emergency projects. Progress toward Sustainable Development Goals (SDGs) is also limited — CAR ranked FIGURE 1.2. HUMAN CAPITAL INDEX SCORES (2019) 166 out of 193 countries in 2020. As of January 20, 2021, more than half of the population needed humanitarian assistance and protection and 40 percent of Central African households are in a situation of acute food insecurity 45 (OCHA 2021). As of April 30, 2021, the number of internally displaced persons (IDPs) due to the post-elections 40 42 40 41 40 unrest was estimated at 729,005, which is 6.9 percent higher than in end-December 2020. In addition, as of May 35 36 31, 2021, there were 694,904 refugees representing approximately 14 percent of CAR’s population.3 30 32 HCI SCORE 30 29 25 20 FIGURE 1.1. A FRAMEWORK FOR ANALYZING FRAGILITY AND CONFLICT IN CAR 15 10 5 0 Cameroon Chad ROC Liberia Sierra Leone CAR FCV average SSA average STATE Center-periphery ACTORS Collaboration Source: Human Capital Index 2020 Country Data. relationships or contestation Social legitimacy or disobedience Unsurprisingly, CAR performs poorly on all six of the HCI component indicators, reflective of the serious systemic issues present and a chronic lack of investment in human capital key sectors. State presence and insecurity In health (World Bank 2021a): Natural resource EXTERNAL • Eighty-eight (88) percent of children born in CAR survive to the age of five. This is lower than the average CITIZENS and elite capture ACTORS survival rates of SSA, CEMAC, and FCV countries. Contributors to child mortality include food insecurity, inadequate feeding practices, lack of hygiene and access to safe water, female illiteracy, early pregnancy, and Porous borders low access to essential health and nutrition services and commodities. Public investments will have to be made on health, social security, and education to reduce CAR’s child mortality. • In CAR, 59 percent of 15-year-olds will survive until age 60, one of the lowest adult survival rates in the world. Extraction and In 2019, the average for FCV and SSA countries was 77 percent and 73 percent, respectively. Prevalent causes of exploitation Peacemaker high adult mortality in CAR are preventable, treatable, and curable—reflective of the historic underinvestment Interest or agitator ARMED in the country’s health system. Among the major causes of adult mortality are conflict, HIV/AIDS, malaria, representation GROUPS malnutrition, and tuberculosis. • Healthy growth (not stunted rate) in CAR is 60.2 percent (MICS 2018, 20194), which means that four out of ten children under five years of age are stunted—higher than the FCV and SSA averages in 2018. These children are at risk of cognitive and physical limitations that could last a lifetime, thus hampering CAR’s human capital Source: World Bank 2022. development. The primary causes of stunting are a lack of food (quality and quantity), frequent illness, poor maternal and childcare practices including early pregnancy and high fertility, inadequate access to nutrition and health services, and unhygienic environments. 2  Peer countries include Economic and Monetary Community of Central Africa (CEMAC in French), as well as fragility, conflict, and violence (FCV) countries in SSA. 12 3  See https://data2.unhcr.org/en/situations/car 4  https://mics.unicef.org/surveys 13 In education, CAR’s outcomes do not fare much better (World Bank 2021a): Recovery and Consolidation Plan and the Mutual Commitment Framework 2017–2023 (Plan de Relèvement et de Consolidation de la Paix en République Centrafricaine et le Cadre d’Engagement Mutuel—RCPCA-CEM). • A child who starts school at age four can expect to complete 4.6 years of school by his 18th birthday—half the SSA average. Factoring in what children actually learn, they receive only 2.7 learning-adjusted years of schooling, Moreover, providing public goods and services, especially in the social sectors, will be crucial to restore the about half of the levels in peers such as Cameroon and the Republic of Congo. In terms of harmonized test legitimacy of state authority in CAR. The provision of public service delivery signals the presence of the state scores, students in CAR rank 369 on a scale where 625 represents advanced attainment and 300 represents and could improve social cohesion. Addressing grievances, inequality (especially spatial disparities between minimum attainment. Bangui and the provinces), and corruption will be essential to strengthen the trust CAR’s population have in • The drivers behind poor education performance are many. Access to education is limited, and few children, their government and to help establish solid foundations for social contract and ensure long-lasting peace. The particularly girls, complete primary and secondary education. Spending on education is low and insufficient to vicious cycle of fragility, inequality, and poverty has resulted in public frustration and mistrust. Expanding public address sector needs such as teachers, classrooms, and school operating expenses. The quality of education services—including in health and education—to the most vulnerable, including IDPs, youth-at-risk, and food is extremely poor. Results from the 2018–19 Early Grade Reading Assessment (EGRA) carried out in Bangui insecure households, will be critical (World Bank 2022). revealed that the proportion of students who could not read a single familiar word in French in one minute was 57 percent in grade 2, 41 percent in grade 3, and 20 percent in grade 4. There are glaring differences in access to basic services between the capital of Bangui and the rest of the country, Box 1.1. How can human capital spending be protected in the face of COVID-19? fueling tensions and feelings of social exclusion. District administration offices are understaffed and short of The pandemic poses substantial risks to human capital through several pathways. The provision of basic funding—in fact, a third of districts indicated not having received any budget allocation for 2016. Most districts do services (health, nutrition, and education) has been disrupted. Containment measures have had dire not have security staff. Access to infrastructure—electricity, mobile phone coverage, banking services, and road consequences for livelihoods and food security. Supply disruptions have increased the price of essential networks—is low. For instance, only 10 percent of districts have network electricity, and only 40 percent of district commodities, including nutritious food. As a result, the COVID-19 crisis is expected to result in an increased capitals have at least one mobile phone provider in the district capital. Half of the districts report that roads to number of stunted children, as well as widespread learning losses as children have lost out on learning Bangui are not accessible throughout the year. Access to basic social services such as public primary schools, time due to school closures. Many kids may never return to school. Global poverty is expected to rise for health centers, and clean water is limited, particularly outside district capitals. Even in the 10 largest localities the first time in two decades. (villages/quartiers) in every district, only half have a functional primary school and 18 percent have functional The fiscal impact of the pandemic is already leading to significant budget cuts across sectors, including health centers, implying that many people are deprived of any access to education and health services. Access education. Education budgets declined after the onset of COVID-19 in 65 percent of low-income countries. to clean water and sanitation systems is a challenge even in the district capitals. Only 36 percent of the districts Government spending on health and social protection (SP) is expected to decline in many countries as report having clean water access points in the capitals. Several provinces in the country have been economically overall fiscal capacity shrinks unless governments can take steps to protect spending in those sectors. and politically neglected, leading to deep-seated grievances and a conducive environment for the emergence of armed groups and conflict (World Bank 2022). Sustainable recovery from the impact of the COVID-19 crisis, especially for the poorest countries, will require efforts on several fronts: This translates to inequalities of opportunity on many fronts. A preference for spending in Bangui and the difficulty of serving a highly dispersed population living in low-density areas has always been a challenge to • To mitigate the risk of permanent human capital losses, the focus should be on identifying and service delivery in CAR. This means that largely poor households, overwhelmingly located in rural areas, bear the financing clear policy priorities. These priorities can include restoring health, protecting and investing in young children, minimizing learning losses, and supporting livelihoods. consequences of these challenges. In 2008, nearly two thirds of CAR’s population lived in rural areas, which were home to about 70 percent of the country’s poor. The country’s Gini coefficient, estimated at 0.543 in 2008, puts • In parallel, investments are needed to make service delivery systems resilient and inclusive in building, CAR among the most unequal countries in the world. protecting, and utilizing human capital. Disparities are seen across geography, income, and gender. For instance, among those 18 years and older, two out • Additional spending may not necessarily lead to better outcomes unless there are positive elements of every five individuals in rural areas have never gone to primary school, and only one out of every five individuals of broader governance in place, such as a whole-of-government approach to agree on and manage in rural areas has at least completed primary school and acquired some secondary schooling (World Bank 2019). priority actions and improving public financial management with a focus on results. In primary education, there are twice as many children from the wealthiest households than from the poorest households. These disparities are even more pronounced at post-primary levels—more than 8 out of every 10 • Not only do essential human capital development expenditures have to be prioritized, but also human capital development must be placed at the center of the budget process, recognizing associated students enrolled in higher education belong to a household from the wealthiest quintile. Overall, girls are likelier expenditure as an accumulation in a country’s productive capacity. to drop out of primary school and remain illiterate, and only a quarter of tertiary-level enrollment is female. • In countries with tight fiscal positions, a multi-year, outcome-oriented approach to budgeting is Investing in human capital development will be key to tackling extreme poverty in CAR. Human capital—the important to protect human capital expenditure from fiscal adjustment. Pursuing cost-effective knowledge, skills, and health that people accumulate throughout their lives, enabling them to achieve their reforms and refocusing budgets toward priorities can help protect critical spending lines from budget potential as productive members of society—is pivotal to the development of individuals and communities, and cuts. to economic growth. Countries can accelerate their economic growth by building and utilizing human capital and leveraging a favorable business climate and good governance. Healthy and well-educated people, free of poverty, contribute not only to economic growth as productive workers but can also bring about a range of positive social Source: World Bank 2021b. and economic externalities such as social cohesion and environmental protection (World Bank 2021b). CAR’s young and fast-growing population5 creates a deep sense of urgency to invest in human development now. Encouragingly, the CAR’s leadership has made human capital development a key priority in its National Peace 5  49 percent of the country’s population is youth under 18 years old. In 2019 this age group was estimated at around 2.4 million people (UN 14 data) and grew at an annual rate of 2.5 percent. 15 There is no question that overall spending levels on human development need to be increased in CAR, Ministry of Finance and Budget (MFB); (ii) payroll data extracted from GIRAFFE for the period 2017–20 from the accompanied by strong improvements in the efficiency and effectiveness of that spending. Spending on MFB; (iii) projections data on macroeconomic variables for the period 2021–30 from the IMF and the World Bank; human development in CAR is low, and unsurprisingly, public spending on health and education (less than 2 (iv) household surveys, the Multiple Indicator Cluster Surveys (MICS) 2000, 2006, 2010, and 2018-2019; the 2016 percent of GDP on each6) is less than the regional average or CAR’s income group (figure 1.3). But CAR cannot do National Communal Monography Survey (Enquête Nationale sur les Monographies Communales—ENMC); (v) The it alone. The country’s domestic revenues are among the lowest in SSA and well below other FCV countries. Tax World Development Indicators (WDI), the World Economic Outlook (WEO), the UNESCO Institute of Statistics (UIS) revenue performance is weak and expected to worsen in the face of the COVID-19 pandemic. For instance, if CAR consulted in May 2021, and the World Population prospects (2019 revision); (vi) various sectoral data described in were to finance the low-income country average per capita spending on health (US$40; World Bank 2019) from each chapter; and (vii) data and information from the interviews with different ministries. its domestic budget, this would amount to US$187 million, equivalent to almost its entire domestic resource mobilization (DRM) (World Bank 2021b). The country has a strong reliance on external assistance. Official grants Data availability and timeliness has presented some challenges to the analysis in this report. First, there are from donor institutions amount to 9.6 percent of GDP in 2019 (up from 5 percent of GDP in 2017), representing several constraints in tracking budget expenditure data on allocations and executions. Due to the limited capacity, more than half of total government revenues. the details on budget data come with a substantial lag and lack rigorous quality assurance. For example, the latest data available for the health national accounts is from 2018. Furthermore, the current budget nomenclature does not allow tracking of the budget allocation at the regional level and cannot be disaggregated, for example, by FIGURE 1.3. SPENDING ON HUMAN CAPITAL DEVELOPMENT VS DEFENSE, level of education. The multisectoral nature of SP and the lack of consensus on a common definition among CAR AND SSA AVERAGE national and international partners add another strain on data collection. Furthermore, it is challenging to link different datasets. For example, there are discrepancies between the information provided on the payroll data and wages and salaries as recorded on the budget data extracted from Ges’Co7, constraining the analysis on the 5 30 wage bill. Second, there are significant challenges in data collection to assess the performance outcomes of the 4.5 HD sectors. For example, the Education Management Information System (EMIS) is lacking critical data needed 25 4 for decision making and geo-referencing of schools for infrastructure development. It relies on a questionnaire 3.5 20 that is manually completed by school administrators, uses centralized data entry, and lacks a system for quality 3 control. Lack of nationally representative household expenditure surveys doesn’t allow proper assessment of 2.5 15 private spending on education, health, and SP. 2 10 1.5 The report is structured as follows. Chapter 2 provides the macro-fiscal context. Chapter 3 focuses on the 1 5 governance aspects of the human development sectors including public financial management (PFM), HRM, 0.5 and procurement. Chapters 4, 5, and 6 examine the education, health, and SP sectors, respectively. In each of 0 0 CAR SSA avg. CAR SSA avg. CAR SSA avg. CAR the sector-specific chapters, the PER assesses expenditure trends and patterns. It then identifies areas where EDUCATION HEALTH SP DEFENCE there are efficiency gains to be made, and fiscally sustainable options for successful reforms in the sector. Three dimensions are used to analyze quality of spending in each sector—equity, efficiency, and effectiveness. as a % of GDP as a % of total govt. expenditure Sources: Calculations from Ministry of Finance and Budget data, World Development Indicators (WDI) 10/2021, WHO Expenditure Database, ILO (2017). REFERENCES Note: Data for Education (CAR, 2020, SSA, 2018); Health (CAR, 2018, SSA, 2018); SP (CAR, 2019, SSA, 2017–19); Defense (average for 2019–20). World Bank. 2019. Central African Republic. Priorities for Ending Poverty and Boosting Shared Prosperity. Systematic Country Diagnostic. June 2019. World Bank, Washington D.C. This Public Expenditure Review (PER) provides an analytical basis to decision makers and stakeholders for the United Nations Office for the Coordination of Humanitarian Affairs (OCHA). 2021. “Central African Republic: formulation of ambitious yet fiscally responsible interventions to improve human capital outcomes in CAR. Situation Report.” Updated January 26, 2021. OCHA, Istanbul. https://reliefweb.int/sites/reliefweb.int/files/ The PER examines public expenditure trends of the education, health, and SP sectors with a focus on adequacy, resources/Situation%20Report%20-%20Central%20African%20Republic%20-%2022%20Jan%202021.pdf. efficiency, and equity of expenditures as well as human resource management (HRM). The primary objective is to World Bank. 2019. “High-Performance Health Financing for Universal Health Coverage.” World bank, Washington, provide analytical insights for government policy development and prioritization strategy as it seeks to achieve DC. a resilient recovery, rebuild its education and health sectors, and establish a strong SP system that will help ———. 2020a. “Central African Republic. Human Capital Index 2020.” Brief. World bank, Washington, DC. https:// the poorest households invest and protect their own human capital. The PER can also serve as a useful source databank.worldbank.org/data/download/hci/HCI_1pager_CAF.pdf?cid=GGH_e_hcpexternal_en_ext. of knowledge and information to development partners seeking to deepen the impact of their support to the human capital development sectors. The recommendations put forth by the PER are those identified as fiscally ———. 2020b. “The Human Capital Index 2020 Update”. World Bank, Washington, DC. https://openknowledge. sustainable and most important for rebuilding and strengthening human capital development sectors, including worldbank.org/handle/10986/34432 a focus on future human resource (HR) recruitment needed in the education and health sectors. ———. 2021a. “4th CAR Economic Update. Investing in Human Capital to Protect the Future.” April 2021. World Bank, Washington, DC. This PER has used several data sources and existing analyses on CAR. First, it draws on existing data sets, including (i) budget data extracted from Ges’Co for the period 2012–20 on domestically financed expenditures from the ———. 2021b. “Investing in Human Capital for a Resilient Recovery: The Role of Public Finance.” April 2021. World Bank, Washington DC. ———. 2022. “Country Economic Memorandum. Central African Republic. From Fragility to Accelerated and Inclusive Growth” 2022. World Bank, Washington DC. 6  The share of actual government expenditure allocated to education accounted on average for only 1.7 percent of GDP and 13.3 percent of total government spending over the period 2018–20. This puts CAR below the SSA average (4.6 percent and 17.8 percent respectively, over the same period) as well as the Global Partnership for Education (GPE) recommended level of 20 percent for countries that have not yet achieved universal primary education. CAR general government health expenditure was 0.7 percent of GDP in 2018, less than the SSA average (1.86 percent) or low- income countries (LIC) average (1.11 percent) (See https://apps.who.int/nha/database). In the SP sector, total SSN spending, from national budget 16 and international partners, was 1.65 percent of GDP, in line with the SSA regional average (1.53 percent) and LIC group average (1.5 percent). 7  This is a computerized budget management information system to strengthen the CAR PFM system 17 CHAPTER 2. MACRO/FISCAL8 The author of the Macro/Fiscal chapter is Diderot Sandjong Tomi. Wilfried Kouame, Raju Singh, and Pierre 8  Mandon provided valuable contributions 18 19 2.1. BACKGROUND FIGURE 2.1. CAR’S ECONOMY STAGNATED FIGURE 2.2. CONTRIBUTION TO REAL GDP IN 2020 GROWTH, 2011–20 CAR has experienced several coups and episodes of conflict that undermined the country’s ability to make the most of its growing workforce. Since gaining independence, CAR has faced several episodes of political instability 10 10 4.1 4.8 4.5 4.5 3.7 that have undermined its economic performance. An unprecedented crisis in 2013 resulted in about 601,746 5 3.3 3.1 3.6 5 1.0 1.0 internally displaced people. In 2020, roughly 681,930 people remained displaced while nearly half of the population 0 0 PERCENTAGE POINTS required humanitarian assistance, with food insecurity affecting about 35 percent of the people. Extreme poverty -5 -5 has trended down in recent years from 75.7 percent in 2014 to 71.4 percent in 2019, but it remains extremely -10 -10 PERCENT high compared to peer countries. Decades of conflicts have undermined the government’s ability to leverage and -15 -15 channel resources toward the achievement of Sustainable Development Goals (SDGs). Also, uncertainty about the -20 -20 security conditions has undermined private capital inflows. The sector remains constrained by several structural -25 challenges, including limited access to finance and infrastructure, low skills, gaps in the legal and regulatory -25 -30 frameworks governing economic activities, and a fragile security environment. As a result, the country ranked 184 -30 -35 out of 193 countries in the latest 2020 Doing Business assessment (World Bank 2020). -35 -40 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 -40 -36.7 Since 2015, CAR has enjoyed relatively sustained economic growth, but the pace of economic diversification 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Agriculture Industry Services GDP remains limited. Economic activity rebounded in 2015, with growth estimated at about 4.1 percent, the highest since independence. This performance has been relatively sustained over the period 2015–19, with growth Sources: CAR’s authorities, IMF and World Bank staff estimates. estimated to average 4.1 percent. In 2020 CAR’s economy grew by 0.9 percent (2.2 percentage lower than in 2019) due to COVID-199. However, the pace of economic diversification remains limited. The country’s exports remain oriented toward raw commodities, including timber, cotton, coffee, and to a lesser extent diamonds and gold, On the demand side, gross fixed investment accounted for most of the growth, but the contribution of private making CAR vulnerable to the volatility of commodity prices. investment remained weak. Gross fixed investment (mainly government investment) accounted for at least 56 percent of growth over the period 2015–20 (figure 2.3). This reflects an increase in public investment to The relative sustained economic growth greatly expanded employment opportunities and drove progress in rehabilitate and rebuild public infrastructure looted during the 2013 crisis and an increase in COVID-19-related poverty reduction. Extreme poverty declined steadily from 75.7 percent in 2014 to 71.4 percent in 2019, reflecting investments. In contrast, the contribution of private sector investment remains subdued (figure 2.4). The fragile dynamic economic activity amid security-related uncertainties. The changing composition of the country’s security conditions, higher aversion of investors to risk, tremendous infrastructure bottlenecks, and limited economy, coupled with gains in education, labor mobility within sectors, and improvement in workforce skills, domestic human capital continue to outweigh the contribution of private investment to growth. Consequently, supported income growth. The latest household surveys, conducted in 2008, showed that the consumption gap the contribution of CAR’s private sector investment has been falling since 2018 and contracted by 2.1 percent between households remains high. in 2020. The fiscal and current account deficits remained on average in the one-digit range through 2015 and 2020. Inflation remains on average below the regional ceiling and continues to track the volatility of food prices. Limited DRM and mounting expenditure pressures over the recent years have contributed to a primary fiscal Inflation accelerated by 4.7 percent (y-o-y) in December 2020 on the back of higher food prices, which accelerated balance in deficit on average over the period 2015–20. In response to the deteriorating fiscal situation, the by 5.3 percent (figures 2.5 and 2.6). The higher inflationary pressure in December was the result of rising insecurity government has adopted several measures to streamline public expenditures, including the reduction of on CAR’s cross-country lifeline, Bangui-Douala, which disrupted the food supply chain and helped push up the exceptional spending procedures as well as the adoption of a public expenditure execution procedure manual. price of imported and locally produced goods. Overall, inflation has remained on average below the convergence However, in 2020 the overall fiscal balance worsened, reaching 3.4 percent compared to a surplus of 1.4 percent criteria of 3 percent since 2019. Factors keeping inflation low include weak private sector investment and subdued in 2019. The deficit was driven by increased capital expenditure due to COVID-19, including the rehabilitation of private sector credit growth. drilling stations and hand-washing devices for public areas (schools, health centers, ministries, and so forth). Inflation remained under the 3 percent regional ceiling and continued to mimic food price volatility. FIGURE 2.3. CONTRIBUTION TO REAL GDP FIGURE 2.4. CONTRIBUTION OF PRIVATE GROWTH, 2011–20 INVESTMENT REMAINS SUBDUED, 2011–20 2.2. RECENT MACROECONOMIC TRENDS AND FISCAL POLICY 40 6 Economic growth in CAR has been relatively sustained since 2015, but economic activity decelerated in 2020 30 PERCENTAGE POINTS due to COVID-19. Growth in real GDP was driven from the supply side by the service sector, with an average 20 4 PERCENTAGE POINTS contribution of about 1.7 percentage points, and the agricultural sector, which accounted for about 1.1 percentage 10 2 points over the review period (figure 2.2). Service sector growth remained limited, with a contribution of 0.5 0 percentage points to GDP. Structural issues related to the tremendous size of informality, limited energy supply, -10 0 and poor infrastructure networks continue to hold back the potential of this sector and its overall contribution -20 -2 to economic activity. In 2020, growth decelerated mainly due to COVID-19, which disrupted economic activity -30 through several internal and external channels. Notwithstanding uncertainty on foreign demand from Asia, the -40 -4 agricultural sector expanded by 4.0 percent as timber production performed better than anticipated. However, -50 -6 the service sector contracted by 1.9 percent as measures to curtail the spread of the virus affected catering and -60 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 hotel services. Private Consumption Government Consumption Government Investment Gross Fixed Investment Net exports Private Gross Fixed Investment 20 9  See https://data.worldbank.org/indicator/NY.GDP.MKTP.KD.ZG?locations=CF Sources: CAR’s authorities, IMF and World Bank staff estimates. 21 FIGURE 2.5. INFLATION REMAINS BELOW THE FIGURE 2.6. INFLATION IN CAR REMAINS FIGURE 2.8. THE CURRENT ACCOUNT DEFICIT HAS DETERIORATED, 2016–20 REGIONAL CEILING, 2019–20 BELOW THAT OF OTHER REGIONAL PEERS 20 50 15 12 10 10 40 PERCENT OF GDP 8 5 PERCENT (Y-O-Y) PERCENT OF GDP 6 0 30 4 -5 2 -10 20 0 -15 -2 -20 10 -4 -25 2016 2017 2018 2019 2020 May-20 May-19 Nov-20 Nov-19 Mar-20 Jul-20 Mar-19 Jul-19 Jan-20 Dec-20 Jan-19 Apr-20 Dec-19 Apr-19 Jun-20 Aug-20 Jun-19 Aug-19 Sep-20 Feb-20 Sep-19 Oct-20 Feb-19 Oct-19 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Balance on goods Balance on services Net income flows Net flows in current transfers Current account balance CPI Foods and Soft Drink Upper bound CAR CEMAC FCV SSA Sources: CAR’s authorities, IMF and World Bank staff estimates. Sources: CAR’s authorities, IMF and World Bank staff estimates. FIGURE 2.9. GOVERNMENT AND CORPORATE CAPITAL FLOWS, 2016–20 The growth of credit to the private sector remains subdued, although commercial banks are well-capitalized. Private sector credit growth stood at 4.4 percent on average in 2020, well below its level of 7.0 percent in 2019 (figure 2.7). As of November 2020, the volume of credit allocated to the private sector amounted to CFAF 170 12 billion (US$314.9 million) while the aggregate balance sheet of local commercial banks was estimated at CFAF 10 315 billion (US$583.6 million). The key factor behind the low supply of private sector credit remains the higher 8 investment risk premium due to the fragile security conditions. PERCENT OF GDP 6 4 FIGURE 2.7. PRIVATE SECTOR CREDIT GROWTH REMAINS SUBDUED, 2015–20 2 0 70 60 -2 50 -4 2016 2017 2018 2019 2020 PERCENT (Y-O-Y) 40 Net flows in capital transfers Direct investment Portfolio investment Other investments Net errors and ommissions 30 Sources: CAR’s authorities, IMF and World Bank staff estimates. 20 10 0 CAR’s overall fiscal deficit widened in 2020 as pressures mounted from the expenditure side due to COVID-19. -10 The overall fiscal balance posted a deficit of 3.4 percent of GDP in 2020, from a surplus of 1.4 percent of GDP in 2019 (figure 2.10). The deficit was mainly driven by increased government spending to fight against COVID-19. -20 The upward shift in government revenue, mainly due to an increase in official grants, could only partly offset the Jan-16 Jan-19 Sep-16 Sep-19 Jan-18 Mar-15 Nov-16 Jul-15 Sep-18 Nov-19 May-17 Nov-18 Mar-16 Jan-17 Mar-19 Jul-16 Sep-17 Jul-19 Mar-18 May-20 Nov-17 Jul-18 Jan-20 Sep-20 May-15 Mar-17 Jul-17 Nov-20 Jan-15 Sep-15 May-16 May-19 Mar-20 Nov-15 Jul-20 May-18 growing pressure from the expenditure side. Over the last five years, the overall fiscal balance has remained in deficit on average, but the deficit has been relatively contained compared to other regional peers. Tremendous Government (Net) Private sector Credit progress has been made by the government since the 2013 crisis to close the deficit and create fiscal space. In 2013, the country posted an overall fiscal deficit of 6.5 percent of GDP, one the highest compared to other regional Sources: CAR’s authorities, IMF and World Bank staff estimates. peers. Thereafter, the implementation of fiscal consolidation reforms to streamline government revenue and leverage domestic resources has helped to significantly narrow the deficit. A budget execution manual has been The current account balance deteriorated in 2020 and remained structurally in deficit over the last five years. adopted, while the commitment and validation of public expenditures has been extended to 15 line ministries Amid uncertainties related to global demand due to COVID-19, CAR’s exports contracted by 19.7 percent in 2020, to reduce expenditures following exceptional procedures.10 As a result, the overall deficit was an average of 0.4 while non-oil imports trended up on the back of increased donor-funded investments to mitigate the effects percent of GDP over the period 2015–20, the lowest level compared to SSA countries (4.3 percent), FCV (4.0 percent), of the pandemic (figure 2.8). As a result, the current account deficit deteriorated from 4.9 percent of GDP in and CEMAC (3.1 percent) (figure 2.11). The need to pursue fiscal consolidation reforms will remain critical to help 2019 to 7.6 percent of GDP in 2020, although offset by a lower-than-expected decline of net flows in current the government channel resources toward social and productive sectors for a better development outcome. transfers. The current account deficit continues to be adequately financed by resilient capital flows (government and corporate), as net flows in capital transfers increased from 3.6 percent of GDP in 2019 to 7.6 percent of GDP 22 in 2020 (figure 2.9). 10  The rate of public expenditure using exceptional procedures has declined from 37 percent in 2017 to about 5 percent in 2020. 23 FIGURE 2.10. FISCAL BALANCE, Decades of conflict have limited fiscal space and could boost its real GDP growth by +0.5 percentage point by 2050 by increasing its average years of schooling to 2010–20 undermined the government’s investments in the median levels of SSA countries (World Bank 2022). Fiscal space should be created to invest in human capital human capital. Political instability and insecurity to support long-term economic growth. This is particularly relevant for the case of CAR, where the level of DRM 30 remain key constraints to CAR’s ability to leverage is weak and external funding for human capital accumulation is limited. Human capital growth in the country is 25 domestic resources for human capital accumulation. projected to reach 0.15 percent by 2050, down from 0.6 percent in 2020 (World Bank 2022). Customs, taxes, and public offices are the main targets PERCENT OF GDP 20 15 of armed groups during conflicts to undermine While undertaking fiscal adjustment measures, ensuring the continuation of public service delivery is critical 10 government revenue collection and its benefits for to avoid medium- and long-term negative effects on human capital outcomes. Budget lines allocated to human 5 citizens in terms of salary payment, investment for capital are often very difficult to identify, and fiscal adjustments sometimes result in cuts in specific categories 0 human capital accumulation, and the maintenance of that are critical to restoring sectors’ efficiency. These spending categories include, among others: learning -5 peace and security. supplies, routine maintenance, professional development, and supervision missions that help strengthening the -10 capacity building of medical personnel or teachers. Hence, identifying and prioritizing budget allocations across 2012 2016 2019 2018 2010 2017 2020e 2011 2014 2015 2013 Also, CAR’s fiscal policy over the last five years sectors for a “socially sensible” fiscal adjustment is fundamental to mitigate the negative impacts on human has been procyclical, reflecting weaknesses in the capital outcomes (World Bank. 2021). CAR should adopt a flexible budget management framework that will help Total Revenues and Grants Total Expenditures Fiscal Balance conduct of fiscal policy. Only looking at the changes in the country move toward budgeting based on human capital development, which will be critical to implement the overall fiscal balance without taking into account cuts in sectors during fiscal adjustment periods efficiently. Sources: CAR’s authorities, IMF and World Bank staff estimates. the business cycle could be misleading on the way the Note: e=estimates; p=projections fiscal policy is conducted. To address this issue, we Since the 2013 political crisis, progress has been made in terms of revenue collection but structural weaknesses estimated the cyclically adjusted fiscal balance and in the tax and customs systems persist. Government revenues have been on an upward trend since 2013 as a calculated the structural fiscal balance. The structural result of multiple factors, including relative improved security conditions since the 2013 political crisis, and FIGURE 2.11. THE FISCAL DEFICIT WAS the implementation of fiscal reforms to leverage domestic resources. Government revenues (including grants) fiscal balance, in this case, is derived as the difference CONTAINED RELATIVE TO FCV PEERS slightly shifted up from 14.1 percent of GDP between 2010–14 to 16.3 percent of GDP over the period 2015–20 as between the unadjusted fiscal balance and the cyclically adjusted fiscal balance (Van der Waaij and grants increased (figure 2.13). In 2020, government revenue reached 21.8 percent of GDP and surpassed the levels 6 in regional peers, mainly due to increased official grants to help the country mitigate the impact of COVID-19 Nord 2000; Girouard and Andre 2005). Change in the 4 structural fiscal balance is the fiscal impulse. A positive (figure 2.14). Tax revenue has increased from 6.8 percent of GDP in 2011–15 to 7.6 percent of GDP in the last five 2 years. Similarly, direct taxes, including corporate and personal income taxes, have increased from 1.4 percent of PERCENT OF GDP fiscal impulse indicates a loose fiscal stance, while a 0 negative fiscal impulse suggests a tighter stance. If the GDP in 2011–14 to 1.6 percent of GDP in 2015–20. Also, indirect taxes (mainly VAT) have increased marginally but -2 fiscal impulse and the output gap co-move in the same remained far below their potential. Furthermore, trade taxes averaged 2.0 percent of GDP over the last five years, -4 direction, then CAR’s fiscal stance has been procyclical unchanged compared to the previous five-year period although the volume of trade in goods and services has -6 over the period and countercyclical otherwise (figure expanded significantly. -8 2.12). -10 There is a need to ensure that CAR’s fiscal policy is 2010 2017 2020e 2011 2014 2015 2013 2012 2016 2019 2018 countercyclical rather than procyclical to maintain CAR CEMAC FCV SSA a minimum level of human capital accumulation even during bad times. Spending proactively to Sources: CAR’s authorities, IMF and World Bank staff estimates. support economic recovery and create jobs during Note: e=estimates; p=projections. episodes of recessions, and cautiously unwinding fiscal stimulus once the output gap closes, is critical FIGURE 2.12. FISCAL IMPULSE AND THE for an efficient and optimal accumulation of human OUTPUT GAP FOR CAR capital. Given the country’s limited fiscal space, the need for a more countercyclical fiscal policy is even Procyclical fiscal policy stronger. This requires that the government improve 0.35 Countercyclical its macroeconomic framework to better monitor the 0.3 fiscal policy economy. Once the economy is operating at its full PERCENT OF GDP 0.25 0.2 potential, the windfall in revenue collections should 0.15 be used optimally, including saving to create space for 0.1 further countercyclical fiscal policy. 0.05 0 As a financially constrained country, CAR needs to -0.05 strengthen its macroeconomic management to -0.1 -0.15 create fiscal space and support long-term economic -0.2 2011-2015 2016-2020 growth for sustained human capital accumulation. Fiscal impulse Output gap As indicated earlier, CAR’s economic activity has been relatively sustained since 2015, but the contribution of Source: World Bank staff estimates using data from CAR’s human capital to economic growth has been minimal. authorities. Although the growth outlook is positive, the country 24 25 FIGURE 2.13. COMPOSITION OF PUBLIC Grants continue to account for a high share of the FIGURE 2.16. TAX REVENUE RELATIVE TO SELECTED COUNTRIES, 2014–18 REVENUE, 2010–20 country’s domestic revenue, leaving CAR vulnerable to cuts in external funding. Official grants from 35 25 donor institutions to CAR averaged 8.2 percent of GDP between 2015–20, up from 5.3 percent of GDP 20 over the period 2011–14. In 2020, grants represented 32.2 32.0 PERCENT OF GDP 31.5 12.6 percent of GDP, more than half of CAR’s domestic 30 15 revenue. Grants disbursement under donor’s budget 10 support has been critical to helping the country to 26.7 finance the deficit of its primary fiscal balance. The 25 5 implication is that in the case of massive cuts in 0 foreign grants, CAR could face significant challenges to 22.7 meet its domestic commitments, including payment 2010 2017 2020e 2011 2014 2015 2013 2019e 2012 2016 2018 21.7 PERCENT OF GDP 20 of agents and civil servants (ACS) and social sector Direct taxes Indirect taxes Trade taxes investment to improve the country’s stock of human 18.6 Other revenue Grants 18.1 capital. Financing human capital to achieve SDGs by 17.4 16.7 16.3 2030 will not be feasible if the country continues to 16.0 16.1 Sources: CAR’s authorities, IMF and World Bank staff estimates. 15 15.1 Note: e=estimates; p=projections rely on foreign financing. The need to strengthen 14.3 13.9 13.7 the country’s tax administration ability to leverage 13.0 12.5 12.1 12.1 domestic resources is therefore imperative. This also 11.3 11.3 FIGURE 2.14. GOVERNMENT REVENUE HAS 10.9 11.0 10 implies that structural weaknesses, including weak SURPASSED THE LEVELS IN REGIONAL PEERS 9.4 tax instruments, tax exemptions, and the low tax IN 2020 8.1 7.6 base, should be addressed. Issues related to business 6.4 5 climate and regulations also need to be addressed. In 30 addition, strengthening the social contract to create 25 an accountability mechanism that encourages citizens to pay their taxes and broadens the tax base are very PERCENT OF GDP 0 20 ZMB MLI COG CAR MWI SYC MOZ MUS GAB TGO ZWE UGA AGO RWA CIV KEN CMR NAM BFA BWA TZA ZAF LSO CPV SEN GNQ GHA ETH MDG good options to consider for reducing dependency on 15 foreign grants. Sources: WDI, World Bank staff calculations. 10 However, the potential for CAR to improve its tax revenue mobilization remains untapped, and the 5 country is currently lagging other SSA countries. CAR’s main tax revenue growth (income, VAT, and trade tax) relative to its tax base remains weak, reflecting 0 CAR’s level of DRM was lower compared to the tax structural challenges in the country’s tax policy and instruments. Since 2018, the growth of income tax revenue 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 revenue ratio of selected African countries over the has been lower than real GDP growth (figure 2.17a). This could suggest that growth over the past years in CAR CAR CEMAC FCV SSA period 2014–18 (figure 2.15 and figure 2.16). Countries is derived from sectors that are difficult to net in terms of income tax. The tremendous size of informality, with higher levels of GDP per capita tend to exhibit which still accounts for about 43 percent of GDP, is a key challenge that prevents the country from reaching its Sources: CAR’s authorities, IMF and World Bank staff estimates. a relatively higher tax-to-GDP ratio. Lesotho (32.2 potential. Also, the agricultural sector, while poorly organized, still accounts for more than 70 percent of CAR’s Note: e=estimates; p=projections percent), Namibia (32.0 percent), and South Africa (31.5 labor force—often local farmers with very marginal contribution to income tax. Although the agricultural sector’s percent) are leading the way in SSA in terms of tax contribution to real GDP over the past year has increased, this has also led to erosion of the effective tax base. FIGURE 2.15. TAX REVENUE AS SHARE OF GDP revenue collection. Ethiopia (8.1 percent), Equatorial VERSUS GDP PER CAPITA, 2014–18 Formalizing the labor force and firms operating in the agricultural sector will help increase the country’s income Guinea (7.6 percent), and CAR (6.4 percent) represent tax revenues. Regarding consumption taxes, the growth in VAT has been quite volatile in relation to its tax base the lower tail of the tax revenue distribution over (final consumption) over the past years (figure 2.17b). This higher volatility reflects to some extent the effect the period. In Rwanda (13.7 percent), one of the CAR’s LSO NAM SYC of discretionary changes, including tax exemptions or the application of zero rating to some goods. In 2016 for 30 aspirational peers, the tax revenue ratio was about two example, VAT exemptions represented about 70 percent of total tax exemptions. As a result, the country has been ZAF times the level of domestic revenue in CAR. This weak losing significant amounts of its domestic revenue that could be efficiently channeled to increase the stock of 25 MOZ BWA performance in the CAR’s ability to leverage domestic human capital. Also, taxes on international trade do not closely trace the growth of its tax base (import growth), resources tracks closely with the decoupling of its tax 20 TGO CPV reflecting structural challenges of the customs administration to properly identify what is being imported (figure MWI ZWE SEN KEN MUS revenue from tax bases. 2.17c). 15 ZMB BFA MLI RWA GHA CMR CIV GAB UGA TZA COG AGO Overall, the weak correlation between tax revenue and corresponding tax bases reflects challenges in tax policy 10 MDG ET H GNQ and instruments, resulting in difficulties in attaining a realistic revenue projection. The need for a regular CAR update of sectoral elasticities is therefore critical to capture the latest dynamic in the structure of the economy 5 0 5000 10000 15000 and improve the contribution of tax revenue in addressing the country’s development challenges. Improving the GDP per capita (constant 2010 US$) country’s ability to leverage tax revenue will require bold policy actions calling for a strong economic growth, sound tax policy and instruments, restricted tax expenditures, and limited sectors issues. 26 Sources: WDI, World Bank staff calculations. 27 FIGURE 2.17. CORRELATION BETWEEN Improving the country’s level of DRM will be key to Investing in people represents a sustainable way to strengthen the social contract between government and GROWTH IN REAL TAX REVENUE AND sustain spending on human capital. Sustaining human taxpayers to mobilize more domestic resources. Although the security conditions remain challenging, there are GROWTH IN REAL TAX BASE REMAINS WEAK capital financing will require improvement in DRM. a few opportunities the government could harness to build or strengthen the social contract with its citizen. Countries with good DRM are more likely to increase Fatalities related to battles and violence against civilians have declined significantly in the second quarter of a. Growth in real income tax revenue budget allocation toward human capital financing 2021. Government efforts with allies have helped improve security conditions in the provinces. Hope for a gradual (World Bank 2021). CAR could explore several options return to normality and stability provides opportunities for the government to increase public expenditures in 150 to adapt its DRM system in favor of human capital. This 200 100 needed sectors. Demands for the provision of public services in sectors such as education, health, and SP are likely includes: (i) broadening the tax base; (ii) reinforcing to increase as the population is gradually returning home, especially in remote areas. Hence, ensuring continuous 80 100 the tax system; (iii) strengthening the social contract 150 public service delivery could help strengthen the social contract between government and citizen and ensure between 60 the government and taxpayers; (iv) learning tax compliance. Strengthening the social contract will also entail the adoption of legal frameworks allowing the PERCENT from best practices and peers’ countries in particular; 100 population and civil society to participate in the decision-making process at the community level. PERCENT PERCENT 40 50 and (v) modernizing tax administration. 20 50 Development partners have helped CAR channel resources toward financing human capital outcomes. The 0 To0broaden the tax base in the short term, there is government has embarked over the last years in a set of public financial management reforms, supported by the 0 need -20 to curb and monitor tax exemptions, strengthen IMF, the World Bank, the European Union, and other development partners. The World Bank approved a series -50 fiscal controls, and explore avenues to increase the -50 of development policy financings (DPF) amounting to about US$200 million between 2018–20. The latest series -40 scope of the excise tax rate. Tax exemptions have been has supported the accumulation of human capital through two key prior actions: (i) the decentralization of the -100 identified -60 as one of the key weakness undermining-100 recruitment of teachers in academic inspection as well as their recruitment in the public administration; and (ii) 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 CAR’s ability to leverage domestic resources. These 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 the provision of a budget envelop in the country’s budget law for targeted free health care in health facilities. The GDP growth Income tax growth rate VAT growth rate Final consumption Imports growth Tax on international trade exemptions represented about 3 percent of the IMF and CAR authorities signed a new Extended Credit Facility (ECF) arrangement program,11 which is expected to country’s tax revenues in 2016 and roughly 21 percent continue until 2022, but the program has been paused as it went off track. b. Growth in real VAT of the primary fiscal deficits (World Bank 2019). Tax exemptions granted to private companies accounted Finding space withing budget could also help increasing human capital financing in CAR but the scope of this for most (70 percent) of total tax exemptions, while measure is limited as the country’s budget is already too low. CAR has experienced several episodes of conflict 100 200 corporate income tax breaks account for another 19 that resulted in massive looting, destruction of public offices and derailed the pace of human capital accumulation. 80 percent of total exemptions. Also, strengthening fiscal As a result, rebuilding the country’s infrastructure network (roads, schools, health facilities) while ensuring 150 controls as well as the country’s recovery capabilities in a minimum level of operating budget is challenging. The yearly budget is very low, less than $728.8 million to 60 the help the country addressing its most growing needs. However, a comprehensive review of budget allocation that 100 short term could help improving tax efficiency. In carefully prioritizes spending across all sectors and shifts resources from non-productive sectors to those with a PERCENT PERCENT 40 2016 for example, about 90 percent of tax revenue had 20 50 been recovered; about 70 percent of uncollected not high impact on human capital outcomes could be considered. 0 tax revenue over the period 2015–16 was in the ICT 0 and forestry sectors. Exploring avenues to increase the -20 excise tax rate on ICT can generate additional resources FIGURE 2.18. THE COMPOSITION OF PUBLIC SPENDING, 2008–16 -50 -40 for human capital financing. Excise tax revenues -60 continue to represent about 0.4 percent of GDP in -100 30 017 2018 2019 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 CAR, with 2009 2010 zero contributions 2011 2012 2013 2014 2015from the 2018 2016 2017 sector. In ICT 2019 x growth rate VAT growth rate Final consumption peer countries, like Rwanda,Tax Imports growth a 10 percent excise on international trade rate is 25 applied on the ICT sector. PERCENT OF GDP c. Growth in tax on international trade In the long term, broadening the tax base for 20 human capital financing will entail tapping into the informal sector, including harnessing the potential 15 200 of property taxes. The informal sector continues to 150 represent a major source of domestic revenue losses. 10 This hidden economy represents about 42.3 percent of 100 the country’s GDP, but its contribution to tax revenue 5 PERCENT is very limited. A community tax base mechanism 50 could be a starting point to lay the foundations of a 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019e 2020e 0 sustained partnership between local communities and Wages and Compensation Goods and Services Interest Payments the government to increase tax contributions of the Current Transfers Capital Expenditures Total Expenditures -50 informal sector. Furthermore, harnessing the potential of property taxes could generate an additional CFAF 12 Sources: CAR’s authorities, IMF and World Bank staff estimates. -100 billion (US$22 million) on a yearly basis. This implies a 017 2018 2019 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 sumption strong political commitment to enforce compliance Imports growth Tax on international trade through the revision of outdated property tax laws, 11  The program focuses on a variety of reforms, including: adopting quantitative rules and performance criteria for better management of the simplification of declarative procedures, and reduction primary fiscal balance; the wage bill; changes in the accumulation of public arrears; improvement in governance and legislation framework; and Source: WDI, World Bank staff calculations. 28 of delays for obtaining a land title. the use of digitalization in public administration to improve transparency and revenue collection. 29 FIGURE 2.19. THE PUBLIC DEBT STOCK FIGURE 2.20. GROSS PUBLIC DEBT HAS Although government revenue has increased since 2017, its level remains low relative to the need to finance AND DEBT-SERVICE PAYMENTS, CONTINUED TO DECLINE RELATIVE TO human capital accumulation. Achieving a higher level of capital accumulation is costly and will require tremendous 2010–20 REGIONAL PEERS government efforts to mobilize domestic resources. Relying on external funding cannot be sustainable to finance the country’s development agenda. Uncertainty about donor support, partly due to unexpected changes in the 80 political context, could delay the level and speed of human capital accumulation. Grants continue to account for 70 1.2 a high share of government revenue, which to some extent represents a major source of vulnerability. Although 70 60 1.0 the country has made significant progress over the past years in reducing dependence on foreign grants, there is PERCENT OF GDP 50 60 scope to accelerate and improve CAR’s ability to leverage domestic resources. PERCENT OF GDP 0.8 40 50 0.6 CAR could undertake bold policy reforms both in the short and medium term to improve its tax revenue 30 40 mobilization for sustained human capital accumulation. In the short run, there is a need to review and update 0.4 30 20 sectoral elasticities as well as the tax bases for a better projection of CAR’s DRM. Realism in tax revenue forecasts 10 0.2 20 is critical to anchor public spending decisions over the medium and long term. Moving forward, there is need for 0 0.0 10 CAR to: (i) ensure promptness in VAT payment return in order to strengthen taxpayer morale and promote private sector investment decisions; and (ii) broaden the tax base through curtailing and monitoring tax exemptions, 2013 2019e 2012 2016 2018 2010 2017 2020p 2011 2014 2015 0 especially on VAT and corporate income taxes. Revenue forgone due to tax exemptions represented about 3 2018 2010 2017 2020e 2011 2014 2015 2013 2012 2016 2019 Domestic Debt Interest Payments,RHS percent of the country’s tax revenue in 2016 and roughly 21 percent of the domestic primary deficit (World Bank External Debt CAR CEMAC FCV SSA 2019). The bulk of these exemptions are granted to private companies, often on an ad hoc basis. Reducing these exemptions, including revision of related tax policies, will require strong political commitments for real changes Sources: CAR’s authorities, IMF and World Bank staff estimates. Sources: CAR’s authorities, IMF and World Bank staff estimates. on the ground. Also, increasing tax recovery rates through targeted audits will be critical to increasing the level of domestic resources in the short run, as the gap between tax projections and realization remains huge and Increased capital spending contributed to expenditure pressures in 2020. Over the past five years, public has widened over the last two years. Since 2010 for example, the tax gap has amounted to CFAF 84.4 billion, spending was an average of 16.2 percent of GDP, up from 15.6 percent of GDP between 2010–14, mainly driven by representing more than one year of civil servants’ salaries in 2020 and about 65.5 percent of the level of domestic higher capital expenditure (figure 2.18). Capital expenditure was estimated at 11.1 percent of GDP in 2020, up from resources collected in 2020. 5.6 percent in 2019 as the government scaled up investment in health, education, and other social sectors to limit the community spread of COVID-19. Also, the government has committed to bridge the social infrastructure deficit Over the long term, there is a need to tax the informal sector and implement business-friendly reforms. In 2019 with the rehabilitation of hospitals, schools, and so forth looted during the 2013 political crisis. Although the the informal sector accounted for more than 42 percent of the country’s GDP (World Bank 2019). Further, this wage bill represents the second highest component of government expenditures, its evolution has been relatively sector is very difficult to net in terms of tax revenue. This growing hidden economy generates unfair competition stable over the past years. In 2019, the share of the wage bill in government expenditure was almost equivalent to to formal and well-established private companies, resulting in lost profits and cash flow and, therefore, profit its level in 2013, reflecting government commitment to avoid creating additional structural spending given CAR’s taxes. Although reducing the size of this hidden and complex network economy is quite challenging, CAR could low level of domestic resources. However, there is still scope for achieving fiscal adjustment through expenditure implement bold policy measures to mitigate the impact of informality. Business-friendly reforms could include reduction without hurting priority spending and growth, as several pockets of inefficiency in public spending simplifying procedures and eliminating transaction costs and constraints limiting the creation and development persist. This includes exceptional spending procedures, which continued to account for more than 5 percent of of local business. In addition, community-based taxation could be implemented to foster local partnerships, as total spending in 2020. Enhancing revenue mobilization and ensuring a sound governance system to prevent well as partnerships between local communities and the government. wastage and improve efficiency and effectiveness of spending will be critical moving forward. Ensuring that CAR’s fiscal policy is countercyclical will be fundamental for human capital accumulation even in CAR’s external and overall debt continues to be at high risk of distress, limiting the country’s ability to invest periods of recession. Over the past five years, CAR’s fiscal policy has been procyclical, meaning that the country in its people. After the 2013 crisis, public debt increased significantly to 63 percent of GDP in 2014 due to an tends to spend more during periods of expansion and much less (or nothing) during economic downturns. Since accumulation of domestic arrears and GDP collapse. Debt has been decreasing since then and is projected to human capital accumulation traces economic ups and down, the country could witness long episodes of zero human follow a downward path over the medium term, mostly driven by domestic arrears’ clearance and the decline capital accumulation during long economic recessions. CAR should ensure that fiscal policy is countercyclical in external borrowing (figure 2.19). High public debt and high risk of debt distress negatively affect capital stock rather procyclical, which is critical for economic recovery and to maintain a minimum level of human capital accumulation and services delivery, as well as civil servants’ recruitment in education, health, and SP sectors. accumulation irrespective of the business cycle. To this end, the country’s macroeconomic framework should be improved to better monitor short-term economic development, leading in turn to more efficient fiscal policy that supports CAR’s development outcomes. 2.3. CONCLUSIONS AND RECOMMENDATIONS Government expenditures should be consolidated and streamlined to help reduce inefficient spending to create fiscal space and resources, which can be efficiently channeled toward social sectors. Since the 2013 political CAR’s economy held up better than expected despite uncertainty introduced by the COVID-19 pandemic. crisis, efforts have been made to streamline government expenditures. A new expenditure execution manual Although real GDP growth decelerated from 3.1 percent in 2019 to 0.9 percent in 2020 due to COVID-1912, economic was adopted to reduce the use of exceptional spending procedures. The commitment and validation of spending activity has remained positive. However, CAR needs to speed up its reform agenda for a better economic recovery, supported by the World Bank DPF series has been extended to 15 line ministries for better budget execution. to create jobs and opportunities for its growing working forces. A strong economic recovery will be critical to In years to come, the introduction of an accounting and budget software “Simba” will help to reduce delays, translating structural changes in economic fundamentals to better tax revenue collection. The contribution of streamline expenditures procedures, reduce the potential for human errors, and improve budget execution. the agricultural sector to real GDP growth has been significant over the past years, but this sector still accounts for a high share of informal employment. As a result, the agricultural sector’s contribution to tax revenue (income and profit tax) is low. 30 12  See https://data.worldbank.org/indicator/NY.GDP.MKTP.KD.ZG?locations=CF 31 TABLE 2.1. PROPOSED REFORMS REFERENCES Proposed reforms Time frame Action: What to do concretely Expected impact Institutions Van der Waaij, D., and C. E. Nord. 2000. “Development and Persistence of Multi-resistance to Antibiotics in Bacteria: An Analysis and a New Approach to this Urgent Problem.” International Journal of Antimicrobial Agents 16(3): Curtail and monitor Short term • Strengthen the committee in • Minimize revenue • Ministry of Finance 191–197. tax exemption, charge of tax exemption and losses due to tax and Budget especially on VAT undertake a revision of the exemption • Ministry of Trade Girouard, N., and C. André. 2005. “Measuring Cyclically-Adjusted Budget Balances for OECD Countries.” OECD and CIT investment charter Economics Department Working Papers, No 434. OECD Publishing. https://doi.org/10.1787/787626008442. • Publish the list of all beneficiaries of tax exemption World Bank. 2019. “Central African Republic Economic Update, November 2019: Strengthening Domestic on the website of Ministry of Revenue Mobilization to Sustain Growth in a Fragile State.” World Bank, Washington, DC. © World Bank. https:// Finance and Budget openknowledge.worldbank.org/handle/10986/32793 License: CC BY 3.0 IGO. Increase tax recovery Short term • Publish the list of all companies • Improve tax recovery • Ministry of Economy ———. 2020. Doing Business 2020. Washington, DC: World Bank. DOI:10.1596/978-1-4648-1440-2. License: Creative rates through that are not up to date in their • Ministry of Finance Commons Attribution CC BY 3.0 IGO. targeted audits and tax returns and Budget other verification • Strengthen capacity building • Ministry of Trade ———. 2021. “Investing in Human Capital for a Resilient Recovery: The Role of Public Finance.” Human Capital measures of tax administrations to use • Ministry of Industry Project, Ministerial Conclave (April 2021). World Bank, Washington, DC. their integrated tax information ———. 2022. “Country Economic Memorandum: Central African Republic - From Fragility To Accelerated and Inclusive management system (SYSTEMIF) software to improve Growth.” World Bank, Washington, DC. https://documents1.worldbank.org/curated/en/099950105022238641/pdf/ productivity P17499601c00dd03208b990cb1b523b9018.pdf • Undertake a systematic rotation of civil servants in charge of audits (IGF), to reduce risk of corruption • Explore avenues to introduce Electronic Billing Machine (EBM) in all formal businesses Tap into the informal Long term • Reduce the number of days it • Attract private sector • Ministry of Economy sector, implement takes to start a business investments • Ministry of Finance business-friendly • Enforce contracts • Reduce revenue and Budget reforms • Undertake discussions with losses due to the • Ministry of Trade communities to Introduce a informal sector • Ministry of Industry community-based taxation in • Communities and the budget Civil Society • Economic and social council Harness the potential Long term • Carry out a national land and • Increase the • Ministry of Economy of property taxes property census with ICASEES contribution of • Ministry of Finance • Digitize declarative procedures property tax to and Budget • Prepare a capacity-building domestic revenue • Ministry of Industry program to support tax • Ministry of Housing administration for better • ICASEES (National recording and monitoring of Institute of Statistics) property taxes • Reduce delays for obtaining land titles Enhance tax policy Medium term • Prepare and adopt a manual • Reduce fraud and • Ministry of Finance and administration of administrative and financial corruption in tax • Customs department and modernize the procedures administration • Tax Department country’s tax system • Strengthen internal control • Increase efficiency • Ministry of Economy mechanisms and introduce risk- of tax and customs based management in public administration administration • Strengthen inspection of services through audits and other verification measures • Scale up the use of UNCTAD’s integrated customs management system (ASYCUDA) in all customs offices and speed up migration to the ASYCUDA platform 32 33 CHAPTER 3. PUBLIC FINANCIAL MANAGEMENT 13 13  The author of the Public Financial Management chapter is Marianne Carolina Caballero Parra. 34 35 3.1. INTRODUCTION 3.2. RECENT HISTORY OF PUBLIC FINANCIAL MANAGEMENT REFORMS The Government of CAR (GoCAR) public financial management systems have come a long way since the 2013 Before the 2013 crisis, the GoCAR had made steady advances on the administration of their human and financial crisis. After a period of large salary arrears, massive civil servant’s absenteeism, and absence of effective financial resources. Software to manage expenses (Ges’Co) had been developed and quarterly budget execution reports controls, caused by the 2013 crisis, the GoCAR was able to restore core PFM functions over the following years and were being produced eight weeks after the end of each quarter. The implementation of the Treasury Single reach a phase of system consolidation. Account had started, and monthly cash flow plans were developed. Financial statements for the 2008 budget year were produced for the first time and submitted to the Court of Accounts in 2011. Payment of salaries through However, considerable challenges remain that are impeding the proper delivery of social services nationwide. secure wire transfers was implemented. These advances were adding up to a more effective and transparent use Despite advances, PFM systems in the social sectors still present failings that directly affect service delivery. The of public resources (World Bank 2018). analysis found the following PFM-related binding constraints to health and education service delivery: The 2013 crisis halted advancements and severely impacted the GoCAR’s financial management systems. By • Poor budget planning and evaluation is causing poor allocative efficiency. Without a thorough and consistent March 2014 the GoCAR had accumulated five months of wage bill arrears and fifteen months of unpaid pensions examination of the effectiveness of the respective ministries’ budgets, it becomes almost impossible to argue and suppliers’ invoices. These arrears, coupled with the security situation, led many civil servants to abandon within budget hearing for changes in budget allocation. The social ministries are not presenting evidence- their posts, effectively handicapping public services like health and education all over the country, as well as core based arguments that support their budget requests, nor are they presenting in time the procurement plans government operations like revenue collection14 and the management and control of expenditures. The Treasury that would accompany their budget. Hence allocations are made mostly on the basis of previous allocations Committee was suspended, the Ges’Co application was not updated, and there were important delays in the and no considerable changes are usually adopted. production of budget reports. New civil servant recruits were being added to the payroll without inputting their information on the HR database, leading to a 16.9 percent increase in payroll between January and December 2013. • Poor public procurement capacity is turning the purchases of key service-oriented goods, like textbooks and medicines, into a fiscal drain on the system. Purchases in the goods and services sectors rarely follow legally As the crisis subsided the GoCAR focused on reactivating core government functions by clearing their wage bill required procurement processes. In the health sector, the deficiencies of public procurement of medicines arrears. The arrears stemming from six months unpaid salary15 of non-security civil servants were cleared.16 The led to the establishment of an autonomous agency that would later collapse in debt, driving external donors payment of salaries was aimed at restoring core government functions by incentivizing staff to return to their to develop alternatives to domestic procurement to provide support. In the education sector the high cost of duty stations (World Bank 2018). textbooks, purchased without following proper channels, is highlighted as a constraint to budget efficiency and service delivery. The payment of arrears to civil servants proved to be an important driver of the resumption of core government functions and services. By March 2014 only 10 percent of the customs directorate’s staff had resumed work and • Poor human resource management practices are binding the deployment of civil servants outside of Bangui. none of the teachers that had abandoned their duties during the crisis had returned to work. By March 2015, 98 Although more civil servants need to be deployed to the rural areas, high rates of absenteeism remain a problem percent of the customs directorate staff had reported for work, and 89.4 percent of teachers that could17 return to for those already posted. The combination of hyper-centralization of human resource (HR) administrative their post had returned. Importantly, an audit of the payroll was carried out which led to the removal of 2,873 non- capacity, lack of local payment capacity, and lack of incentives to work outside of Bangui causes absenteeism. eligible18 civil servants from the payroll, along with an update of HR data of civil servants on the payroll system As explained in detail in the respective chapters, the quantity and capacity of HR outside of Bangui is a clear (World Bank 2018). constraint to the quality of health and education services. These challenges are all related to the overarching problems of (i) the absence of local payment capacity, which means civil servants have to go to Bangui, or the The imposition of emergency expenditure controls also proved fundamental and paved the way to rebuilding the nearest Bank Agency which is usually many hours away, to collect their salaries; (ii) the absence of an HR policy financial management railings needed for the management of public resources. The Central Treasury Accounting that rewards or recognizes civil servants appropriately when they are posted outside of Bangui; and (iii) the Agency (Agence Comptable Centrale du Trésor—ACCT) was created, and a Central Accounting agent recruited. This was absence of an HR system that can help manage the long- and short-term career performance of civil servants. crucial for implementing verification procedures on expenditure accounting and disbursement, and for producing in- This latter system would also need to be operationally linked to the payroll system and have the ability to year and annual consolidated execution reports. Though the measure at first created considerable friction between discern whether the civil servant is indeed in their post and react immediately if they are not. different parts of the GoCAR and the ACCT, it was successful in limiting leakages during a time of high uncertainty. • The absence of local payment capacity also extends to the domestically financed SP sector, which continues By 2017 the country was in a new phase of stabilization which allowed the GoCAR to go from an emergency to use antiquated payment systems. For example, the higher education scholarships, which amount to about phase focused on reactivation of core functions, to one of strengthening of core capacities for resource half of nationally funded SSN programs, are paid in cash in Bangui in the respective university using a list of management. In October 2016, the “2017–2021 National Plan for Recovery and Peace Building” was adopted, beneficiaries. The rest of the cash transfers program uses costly mechanisms, financed by external donors, to followed in November 2016 by a donor conference where partners pledged US$2.2 billion19 to the development of reach areas outside of Bangui. If the domestically financed SP system were to expand, the payment system the country. The Public Expenditure and Investment Management Reform Project (Projet d’Appui à la Gestion de would need to be updated to be able to extend to areas outside of Bangui. Dépenses et Investissements et au Reformes—AGIR) project was approved by the World Bank Board in June 2017 “to improve the management and transparency of public expenditures and public investments”20 with an initial • No public investment capacity will bind the sectors when/if the external funds diminish. Interactions budget of US$10 million, thus ushering a phase of strengthening core capacities. between domestically and externally funded public investment in social sectors affect the capacity to deliver domestically financed infrastructure. Like other countries highly dependent on external assistance, spending units have assumed the reality that most infrastructure is externally financed and hence focus mainly on other expenditures that would fall under that line, such as small maintenance works, vehicles, and office 14  Note that this chapter does not analyze elements of DRM. Though DRM is an important element of public financial management, a decision was made to focus on expenditures, as they relate directly to the delivery of (social) public services. furnishings. This means that the domestic public investment system has not developed the capacity to 15  May to August 2014, June 2015, and September 2015. manage infrastructure projects, but rather focuses on lower-cost short-term interventions that are unlikely 16  This was done through the financial support of the World Bank-financed Emergency Public Services Response (EPSR) project. The EPSR was to be transformational. This is reflected in CAR’s public investment program, where multiple expenditure designed to address the immediate crisis on the expenditure side while helping recover the GoCAR’s capacity to gather and manage its own resources. lines could hardly be called public investment. This situation, though arguably natural for the level of fiscal 17  Percentage of teachers who have resumed work in the districts where security has improved. space in CAR, could create negative long-term effects on the country’s ability to carry out its domestically 18  Civil servants that were deceased, retired, and “other.” financedinvestments. 19  Of which the World Bank pledged US$500 million. 36 20  Project Development Objective for the Public Expenditure and Investment Management Reform Project (P161730). 37 The GoCAR was then ready to begin the replacement of the decrepit Ges’Co system, reactivate the production There is no programmatic evaluation of the domestically funded budgetary expenditures, but budget execution of budget reports and key treasury management activities, support the supervision of the RCPCA, and improve reports are published regularly. The most reliable substantive evaluation of the effectiveness of budget public investment management (PIM). The GoCAR was able to invest21 on core resource management functions expenditures comes from the RCPCA Secretariat (see section 3.6.1 for more details), but these reports focus and tools that would help return the GoCAR’s performance to levels from before the 2013 crisis. Indeed, comparison mainly on externally funded projects that make up the bulk of the RCPCA funding. The MFB has been regularly of government competence before the 2013 crisis with the present is telling: the GoCAR can now produce more publishing quarterly budget execution reports since 2017, including details on social expenditures since 2017, and fiscal information and budget execution reports that it did in 2013 and it can pay its salaries reliably and on time. the MEPC has been publishing yearly public investment execution reports since 2018. No other ministry prepares Yet, challenges from before the 2013 crisis persist: HR information continues to be disjointed from the salary a programmatic evaluation of their yearly expenditures. system, procurement is riddled with inefficiency and opacity, and the public investment system is in its infancy. Without a through and consistent examination of the effectiveness of the respective ministries’ budgets, it becomes almost impossible to argue within budget hearing for changes in budget allocation. The social ministries 3.3. DECENTRALIZATION, DECONCENTRATION, AND PUBLIC FINANCIAL are not presenting evidence-based arguments that support their budget requests, nor are they presenting in time the procurement plans that would accompany their budget. Hence, allocations are made mostly on the basis of MANAGEMENT previous allocations and no considerable changes are usually adopted. As of 2020, of the 19,530 civil servants working as civilians in the GoCAR, 68 percent of them were posted in Bangui, where 18 percent of the population lives.22 The concentration of civil servants in Bangui reflects the lack of state presence in most of the country’s territory. This in part due to consistent security threats outside of 3.5. BUDGET EXECUTION PERFORMANCE 2017–2025 Bangui, but also related to a clear preference from civil servants to remain in Bangui where the public services and The GoCAR’s domestically financed budget26 execution rates have been increasing since the 2013 crisis. The infrastructure are much better than in the rest of the country. budget execution rate went from 68.7 percent in 2017 to 91 percent in 2020. Importantly, when we focus on operational expenses that exclude debt repayments and finance fees, we see much more solid levels of budget The 2019 peace accord includes commitments to decentralize resources outside of Bangui, in response to the execution, reaching levels above 94 percent since 2018 (see figure 3.1 and box 3.1). complaints of citizens that have not reaped the benefits of a state highly concentrated in the capital. The accord’s most tangible commitment to this end is the celebration of the first local elections in 25 years, expected to be held in the last quarter of 2021, as well as the approval of a decentralization law. The local elections would be crucial first step toward political decentralization, whereby the formal power structures of democracy could now reach localities. FIGURE 3.1. BUDGET EXECUTION RATES, EXCLUDING EXTERNALLY FINANCED PUBLIC Nevertheless, the country would still need a better process through which to move resources and administration INVESTMENTS, 2017–20 from the center (Bangui) closer to the service area (outside of Bangui); this would be a deconcentration process.23 100 A new Territorial Administration Law,24 approved in December 2020, provides further competencies to the 95 prefectures to influence the delivery of public services, and the law could be an opportunity to improve the 90 regional management of services like health and education. Details of interaction between the ministries’ 85 PERCENT 80 deconcentrated units and the prefectures are yet to be spelled out, but importantly, ministries’ must be prepared 75 to change the way they work in the regions. Thus, this chapter considers relevant aspects of the deconcentration 70 process while discussing PFM in human development sectors. 65 60 55 50 3.4. BUDGET PREPARATION, APPROVAL, AND EVALUATION 2017 2018 2019 2020 YEAR Total expenditures Total operational expenditures The preparation and approval of the national budget happens generally on the timeline and using the procedures set by law. The yearly process of budget preparation, including setting expenditure ceilings, calling for budget hearings, approving a final draft (for both recurrent and public investment budget), and submitting to Source: Central African Republic, Ministry of Finance and Budget, 2018; 2019; 2020; 2021. Note: The operational expenses exclude debt payments and financial fees expenditures. the National Assembly, largely follows the schedule set by the 2018 Finance Law. Domestic revenue projections have resulted in a realization rate hovering above 99 percent since 2018, while debt management procedures have been carried out in line with the requirements of the existing IMF Extended Credit Facilities. The social sectors have also seen improvements in the execution rates in the last four years, though the 2020 budget year exhibited setbacks for the health and SP sectors. All sectors have avoided arrears in their wage bill, However, the influence of social sectors in the national budget process is limited, and generally follows a but the education sector27 has exhibited a generally higher execution rate than its peers among the remaining path-dependent process. Despite the existence of long-term sectoral plans, such as in the education sector, the expenditures.28 Notwithstanding, the health and social affairs sectors had both seen an upward trend in the respective social ministries’ budget proposals mostly rely on the past years’ allocations, while any major funding changes are expected to come from external funding. Although a three-year Public Investment Program is prepared by the Ministry of Economy, Planning and Cooperation (MEPC), this is mostly seen as a “wish-list” with 25  We focus on the 2017–20 period because the analysis is based on the MFB’s Budget Execution Reports, which offer the most consistent few binding outcomes (see Public Investment section 3.6.1 for further details). and reliable information on budget execution. Moreover, although it is possible to obtain some information before the 2017 budget year, as mentioned on the recent history section above, core PFM functions were considerably challenged before that budget year, hence the systems that we are reviewing today are not comparable to those in place before 2017. 26  In this chapter we focus on domestically financed expenditures, which are the GoCAR’s budgeted and disbursed amounts excluding 21  With the help of the AGIR project. externally financed public investment. We will be explicit when we refer to externally financed expenditures. The terms “domestically financed 22  Based on payroll data from the Ministry of Finance. expenditures/budget” and “expenditures/budget” are used interchangeably. 23  For the purposes of this PER we will focus mostly on deconcentration of resources. 27  The classification of sector is based on classifications in the MFB’s Budget Execution Reports. 24  Most of the content of this law was originally on the first draft of the Decentralization Law. The proponents of the law decided to separate 28  The MFB does not include in the Budget Execution Reports the execution of the wage bill by sectors, but according to the respective the two issues into two separate laws: the Decentralization Law, passed in February 2020, and the Territorial Administration Law, passed in ministries the wage bill execution has been 100 percent for the last four years. To sharpen focus on the performance of the budget, we then 38 December 2020. exclude the wage bill execution rate from most of the budget performance analysis. 39 execution rates since 2017 until the year 2020, when their rates fell to 71.4 and 50.8 percent respectively. For FIGURE 3.2. BUDGET PERFORMANCE IN THE SOCIAL SECTORS, OPERATIONAL EXPENDITURES, the case of the health sector, the fall in execution rates was driven by lower execution of transfers and grants EXCLUDING EXTERNALLY FINANCED INVESTMENTS AND PERSONNEL EXPENSES, 2017–20 and public investments, while the social affairs fall in execution rates was driven mainly by particularly low (43 percent) execution of transfers and grants expenditures. a. Education sector, budget execution rate b. Education sector, executed expenditures TOTAL OPERATIONAL EXPENSES, 9,000,000 20,000,000 140.0 8,000,000 18,000,000 120.0 16,000,000 THOUSHAND FCFA 7,000,000 100.0 THOUSAND FCFA Box 3.1. A focus on domestically funded expenditures 80.0 6,000,000 14,000,000 PERCENT 12,000,000 5,000,000 60.0 10,000,000 Externally financed public investments are a fundamental component of CAR’s development process. 40.0 4,000,000 8,000,000 3,000,000 Externally funded public investment has comprised an average of 26.5 percent of total budgeted expenditures 20.0 2,000,000 6,000,000 4,000,000 over the last four years (see figure B3.1.1), reaching as high as 34.2 percent of total budget in 2020. 0.0 1,000,000 2,000,000 2017 2018 2019 2020 - - YEAR YEAR Goods and Services(a) Transfers and grants (b) FIGURE B3.1.1. PUBLIC INVESTMENT PROPORTIONS OVER TOTAL BUDGET, 2017–20 Public Investment Total operational expenses(c) Goods and Services(a) Public Investment Transfers and grants (b) Total operational expenses 50% c. Health sector, execution rate d. Health sector, executed expenditures 45% 40% TOTAL OPERATIONAL EXPENSES, 120.0 9,000,000 20,000,000 THOUSAND CFAF 8,000,000 18,000,000 35% 100.0 7,000,000 16,000,000 THOUSAND FCFA 30% 80.0 14,000,000 THOUSAND FCFA 6,000,000 PERCENT 12,000,000 25% 60.0 5,000,000 10,000,000 20% 40.0 4,000,000 8,000,000 3,000,000 15% 6,000,000 20.0 2,000,000 4,000,000 10% 1,000,000 2,000,000 0.0 5% 2017 2018 2019 2020 - - YEAR 2017 2018 2019 2020 0% YEAR 2017 2018 2019 2020 Goods and Services(a) Transfers and grants (b) Goods and Services(a) Transfers and grants (b) YEAR Investissement Total operational expenses(c) Public Investment Total operational expenses Public Investment Domestically Financed Public Investment Externally Financed e. Social affairs sector, budget execution rate f. Social affairs sector, executed expenditures Source: Central African Republic, Ministry of Finance and Budget 2018; 2019; 2020; 2021. TOTAL OPERATIONAL EXPENDITURES, 120.0 9,000,000 20,000,000 8,000,000 18,000,000 100.0 Domestically and externally funded public investment expenditures go through fundamentally 16,000,000 THOUSAND FCFA 7,000,000 80.0 14,000,000 6,000,000 different PFM systems in CAR and as such cannot be assessed concurrently. Though externally funded PERCENT 12,000,000 THOUSAND FCFA 5,000,000 60.0 projects in CAR are not officially exempted from local financial controls, in practical terms, most control 4,000,000 10,000,000 8,000,000 40.0 activities are not carried out by the government because they assume that the funders’ processes will 3,000,000 2,000,000 6,000,000 20.0 4,000,000 ensure sufficient control. In tandem, to ease implementation in a context of urgent needs and extremely 1,000,000 2,000,000 0.0 low capacity, funders have tended to use exceptional procedures in CAR, which allow them to forgo the 2017 2018 2019 2020 - 2017 2018 2019 2020 - YEAR YEAR use of local systems. Hence, the bottlenecks to service delivery that could arise from, for example, slow or Goods and Services(a) Transfers and grants (b) Goods and Services(a) Transfers and grants (b) inefficient procurement processes, would not affect an externally funded project. Public Investment Total operational expenditures(c) Public Investment Total operational expenditures Local PFM systems need to be strengthened with the medium-term aim of using them for the Source: Central African Republic, Ministry of Finance and Budget 2018; 2019; 2020; 2021. execution of externally financed projects. The purpose of this chapter’s analysis is to delve into the Note: The source excludes personnel expenditures. According to the respective ministries the execution of the personnel budget was 100 bottlenecks caused by the local systems on domestically funded service delivery. This means that percent during the period. alternative mechanisms set up by external funders that are not using the traditional expenditure control (a) Before 2019 “Operating Expenses” systems are not considered in this chapter.* (b) Before 2019 “Intervention Expenditures” *Among the mechanisms excluded would be the mechanisms used to purchase the majority of publicly provided medicines, all of which use Public investment execution rates have been quite different between the sectors, with education exhibiting externally funded resources that do not go through the local traditional procurement system. steady improvements, and health more volatile levels. The education sector’s public investment budget execution rate went from 58.7 percent in 2017 to 103.7 percent in 2020 (figure 3.2, panel a), while the health sector has not been able to sustain a steady level of execution in public investment expenditures (figure 3.2, panel b). All sectors exhibit their highest execution rates in goods and services mainly because expenditures on this line are relatively predictable and don’t require new procurement processes. The high levels of budget execution We see the opposite behavior to public investment on the grants and subsidies line; that is, the health sector in goods and services (see figure 3.2) reflect the fact that this line includes the payment of contractual workers exhibits sustained improvements while the education sector’s execution rate has recently stagnated. The steady in core government functions, such as teachers. These payments are recurrent and are easily budgeted for and increase in the health sector’s budget execution on grants and subsidies shows higher government financing to executed, that is, they are not burdened by in-year procurement processes that can delay execution, and they are the regional offices, as the line is mainly devoted to transfers to the regional offices. The 2020 drop in execution generally given the same priority as the payment of salaries.29 reflects an in-year change in budgetary priorities due to the COVID-19 pandemic. In the case of education, the volatile performance of the grants and subsidies line is mainly explained by the erratic payment of scholarships, which is the main driver of the budgetary line. 40 29  Though the payments don’t arrive on time during the year; see Chapter 4 on education for details. 41 3.6. CORE PUBLIC FINANCIAL MANAGEMENT SYSTEMS Box 3.2. CAR PIMA assessment highlights • Budgetary rules: These are set in accordance with the commitments made with the IMF and CEMAC, containing the deficit and the debt-to-GDP ratio, and controlling the debt trajectory. 3.6.1. Public investment • National and sectoral planning: The MEPC is responsible for the execution of national development policy. It houses Developments since 2013 the RCPCA, whose operationalization and essential articulation with sectoral strategies is the main challenge. • Coordination between entities: To ensure good coordination between non-central entities, a law adopted in 2020 now regulates the governance of public enterprises and establishments. A law on decentralization is being finalized After the 2013 crisis, advances on PIM were limited as the fiscal space did not allow for capital expenditures. There to update the current legal framework, which dates back to 1988.* had been no investment projects appraised between 2013 and 2015. To be clear: it is not that investment projects • Project evaluation: A 2009 manual on the management and programming of public investments, which has not that were approved were not appraised, but rather that no investment projects were started during the period. been used by the sector, defines the relevant concepts and procedures in terms of project management. • Other infrastructure financing: The conditions for infrastructure development are guaranteed by the legal and As the country stabilized the GoCAR focused on better reporting and planning of public investment regulatory framework, while a law governs public-private partnerships (PPP). expenditures. The MEPC30 has so far delivered three reports on public investment execution; two reports on • Multi-year budgeting: This practice was instituted by an organic law of 2018. However, the provisions of this law three-year public investment programs; and an assessment based on the IMF/World Bank’s Public Investment have not been fully implemented. • Completeness and unity of budget: The law of 2018 institutes the exhaustiveness and unity of the budget. The Management Assessment (PIMA) framework (see box 3.2). In addition, technical and financial assistance has been law provides, in article 22, that the budgeting of investments be distinguished in commitment authorization and provided to the operation of the RCPCA Secretariat, which was charged with monitoring implementation of the payment appropriation. 2017–21 RCPCA. This was done under the logic that the RCPCA would be a guiding force for medium- to long-term • Capital budgeting: There is no regulatory or legislative provision that prioritizes the financing and execution of investments in the country. ongoing projects over new projects. • Financing of maintenance activities: To ensure the sustainability of the infrastructure, maintenance and upkeep Current context costs are considered. The budgetary nomenclature provides for budget codes for the upkeep and maintenance of works and equipment. • Project selection: The selection of investment projects is made during the investment budget conference. The Most public investment in CAR is done through externally funded projects, which are monitored through the Letter Circular, sent to the sectors by the Prime Minister, sets out the priority sectors and four strategic pillars that RCPCA mandate. Externally funded projects, which are assumed to be public investment, have constituted an serve as a reference. average 76 percent of total public investment for the last four years (see figure 3.3). These projects are tracked • Procurement: Although there is a legal framework dating from 2008, which ensures openness and transparency and monitored by the RCPCA Secretariat as they are related to the commitments made on the RCPCA. The RCPCA in public procurement procedures, it lacks a digital platform dedicated to these markets. The revision in this area Secretariat, with the support of the AGIR project, is regularly delivering implementation reports on the RCPCA and plans to integrate CEMAC procedures. • Availability of funding: The principle of integrating external financing into the Treasury’s single account was is currently implementing the use of KoBoToolbox31 for the remote tracking of ongoing projects. instituted with the operationalization of the account in 2017. A central and global commitment plan is maintained by the General Budget Directorate, but the sectoral departments do not have control over their own plans, either in their preparation or in their execution. FIGURE 3.3. BUDGETED PUBLIC INVESTMENTS BY FUNDING SOURCE, 2017–20 • Portfolio management and monitoring: The modification of investment projects during the execution phase, according to the distribution of credits between programs of the same ministry or institution or between allocations, is permitted. 160,000,000 • Project implementation management: Structural projects are mainly financed from external resources and 140,000,000 executed according to the management rules of the donors. THOUSAND CFAF 120,000,000 • Monitoring of public assets: The normative framework for public financial management in CAR provides for asset 100,000,000 accounting, but this is not yet practiced. 80,000,000 60,000,000 40,000,000 FIGURE B3.2.1. ASSESSMENT OF CAR PUBLIC INVESTMENT MANAGEMENT 20,000,000 - INDICATORS BASED ON PIMA METHODOLOGY 2017 2018 2019 2020 YEAR Public Investment Domestically Financed Public Investment Externally Financed Objectifs et règles budgétaires 3 Planification nationale et sectorielle Suivi des actifs publics Gestion de l’exécution des projets Coordination entre entités Source: Central African Republic, Ministry of Finance and Budget 2018; 2019; 2020; 2021. 2 Gestion et suivi du portefeuille 1 Évaluation des projets The PIMA assessment evidenced the extremely low capacity for managing domestically financed public 0 investment in CAR. The domestically financed public investment system in CAR is led by the MEPC, specifically Disponibilité du financement Autre financement de l’infrastructure its General Directorate for Economic Planning (Direction Générale de la Programmation Economique—DGPE). Budgétisation pluriannuelle Though the PIMA assessment considered the activities of the RCPCA Secretariat, most of it was focused on the Marchés publics operations of the MEPC, because the formal institutional framework deems this ministry at the helm of PIM. The Sélection des projets Exhaustivité et unité du budget results of the assessment were discouraging: all but three out of the fifteen elements assessed were marked as Financement des activités d’entretien Budgétisation des investissements having medium practical effectiveness, and the rest were marked weak. Interestingly, though not uncommon, Cadre institutionel Effectivité de pratiques the institutional framework was deemed in much better shape, with the majority of elements scored as having medium effectiveness rather than weak (see box 3.2). Note: Scores of 1–3 denote weak, medium, and strong capabilities. 30  Mainly through the AGIR project. Source: 2AC 2021. 42 31  See https://www.kobotoolbox.org/. *Since, the decentralization and territorial administration laws were enacted in February and December 2020 respectively. 43 Among the challenges, one bottleneck stands out within the process of selecting and budgeting projects: Regulatory Agency (Autorité de régulation des marchés publics—ARMP) to undertake mandatory procurement the initiation of new projects that take over funds needed to conclude others. Although the 2018 finance law audits. Some of this support, not all of which was provided as priorities and timelines shifted, helped deliver the requires a differentiation between engagement authorizations and payment credits on the public investment Annual Procurement Plans for all ministries. AGIR support also allowed for some notices for public bidding to budget, the practice has not been adopted. This means a public investment project could outspend the treasury be published, and the 2017 and 2018 audits to be carried out; the audit for 2019 is ongoing. The audits show the availability through the year, hence creating a liability. Importantly, this liability spills through new and ongoing extent to which inappropriate procurement practices are carried out. projects, and there is no regulatory or practical provision to protect the conclusion of ongoing projects over new ones. Consequently, new liabilities can be created while arrears are accumulated on ongoing projects (2AC 2021). Current context Weak procurement planning at all levels causes erratic payments and physical advancements. This challenge, The GoCAR’s procurement system has very little capacity to meet minimum standards of effectiveness and which is a part of the overarching challenge of weak procurement systems, also affects PIM. Procurement plans transparency. The system is comprised of the regulatory agency ARMP, the implementing agency DGMP, and the are not developed in time or accurately, which then hinders in-year treasury management, eventually causing deconcentrated service agencies (Services de Passation des Marchés publics—SPMPs) (see box 3.3). The different long delays in payments which halt constructions (see section 3.6.2, Public Procurement System). roles between these agencies could be better legally defined, but more importantly, they are not well understood by agents in the process. The ARMP and the SPMPs exhibit very low capacity and can hardly be said to deliver their There are no decentralized public investment provisions, and regional equity is not considered in the planning. mission. Indeed, SPMPs are consistently bypassed within their own ministries and hence do not fully control or There is no capacity outside of Bangui for public entities to contribute to or carry out any of the stages of PIM. In monitor all procurement processes with their entity. There is no capacity for procurement processes to happen addition, the public investment program prepared does not reflect regional considerations. That is, the program outside of Bangui. Last, the whole system is ruled by a 2008 law that is in urgent need of an update, which could does not note the location of the beneficiaries of projects and hence it is not possible to assess the regional include elements like the online publication of bidding documents. impact it would have. Bottlenecks to service delivery Box 3.3. Public procurement agencies and performance The interactions between domestically and externally funded public investment budget expenditures in social The regulatory authority: The Public Procurement Regulatory Agency (Autorité de régulation des sectors are affecting the capacity to deliver domestically financed infrastructure. Spending units have assumed marchés publics—ARMP) has an (ex post) regulatory role along with the leadership on policy and capacity the reality that most infrastructure is externally financed and hence focus mainly on other expenditures that building. The ex post regulation of procurement processes is carried out mainly through a Committee would fall under that line, such as small maintenance works, vehicles, and office furnishings. This means the for the Management of Complaints (Comité des Règlement des Différends—CRD) that would rule on domestically financed PIM system has not developed the capacity to manage infrastructure projects but rather contentious cases. This CRD has not ruled on contentious activities in years, while the last know case focuses on lower-cost short-term interventions that are unlikely to be transformational. This is reflected in the still not ruled on dates from 2015. The CRD is currently for all practical purposes inactive due to a lack of public investment program, where multiple expenditure lines could hardly be called public investment.32 qualified personnel and operating budget. The challenge to enhance PIM systems is one of supply and demand. The low capacity of the PIM system would The control authority: The General Directorate for Procurement (Direction générale des Marchés not allow for a considerable scale up of the quality and level of domestically financed public (capital) investment Publics—DGMP) is housed at the Ministry of Finance and serves as the control authority, overseeing (ex (supply). At the moment there is little demand for enhancements of the PIM system as there are no allocations ante) the larger part of procurement processes. The DGMP examines and approves procurement plans for for more long-lasting public investment, that is, infrastructure. spending agencies, including the type of procurement process selected (for example, single source versus open market. A review of the records of the DGMP in 2019 exhibited a worrisome use of “emergency” or The absence of decentralized public investment planning limits base communities’ ability to effectively extraordinary contracting procedures. Specifically, of the 80 opinions issues by the DGMP: influence local development. Base communities33 currently have no way of participating in the development of • 47 non-objections were granted for contracts by direct agreement due to “emergency” or “extreme the public investment program. Their role in formulation of local development plans has been laid out in the 2020 emergency”; Decentralization Law, but the mechanisms for these plans to influence said program have not been developed. • 9 non-objections were formulated for direct agreement procedures following unsuccessful tenders; Importantly, this means communities have no influence over the capital resources that could be allocated to and improve the health and education of their members. • 24 objections were formulated, yet it was also noted that some contracting authorities exceed the refusal to grant authorization to change the method of procurement. 3.6.2. Public procurement system The deconcentrated implementing authorities: The Ministry of Health and the Ministry of Education host pilot deconcentrated service agencies (Services de Passation des Marchés publics—SPMPs). These Developments since 2013 SPMPs are expected to carry out the procurement processes not only for their respective ministries but also for a set of other ministries.* These SPMPS were supposed to be financed by charging fees for their The procurement system has not been at the forefront of GoCAR’s reform agenda, and despite some technical services but this capability has never been properly developed. Hence the units are left with no resources assistance from the World Bank, much remains to be done to enhance the system’s transparency and efficiency. and their roles are mainly effectively taken over by the Resource Management Units of each ministry. The AGIR project aimed to provide technical assistance to sensitize participants in the procurement process, as well as office and computer equipment and training and capacity building to strengthen the procurement processes. Also, the projects would establish a simple procurement monitoring system within the General Directorate for Source: 2AC. 2020. Procurement (Direction générale des Marchés Publics—DGMP) and in the procurement units of the targeted *The Ministry of Health handles 9 other ministries and the Ministry of Education handles 12. ministries, including health and education. Furthermore, support would be provided to the Public Procurement 32  As an illustration, the Ministry of Health proposed the purchase of bug repellent nets as part of its public investment program (République Centrafricaine 2020). 33  From the term “Comunitées de Base” used in the decentralization law to refer to the non-formalized local communities that would then be 44 represented by the formal local governments. 45 Bottlenecks to service delivery In the education sector, where domestic funding is the main source or service-oriented purchases, the low capacity and transparency of the public procurement system is leading to overpriced purchases. Goods and services exhibit the highest levels of budget execution within operational expenses, yet as mentioned above these purchases are rarely carried out through the legally required procurement processes. A good example of the consequences is mentioned in Chapter 3 on Education, where the high cost of textbooks is highlighted as a constraint to budget efficiency and service delivery. In the health sector, the deficiencies of public procurement of medicines led to the establishment of an autonomous agency that would later financially collapse, driving external donors to develop other alternatives to provide support. The now-defunct national medicine supply unit (Unité de Cessions des Médicaments—UCM) was created in 1994 as a technical unit within the Ministry of Health. The UCM was then transformed into a statutory body (établissement public) with its own governance bodies. Its main sources of revenue were donor contributions and budget appropriations, through a dedicated fund. However, declining contributions and a high cost base (including labor costs) led to growing financial difficulties. UCM accumulated losses and significant bank debt and trade arrears, with liabilities reaching almost CFAF 2 billion in 2016. As a result of these problems, donors became less and less willing to support UCM. Currently, it is non-operational, although it retains significant assets (including two warehouses used by the Global Fund and the World Food Programme) and some personnel. 3.6.3. Human resources management Developments since 2013 The GoCAR has come a long way from a point of high absenteeism driven by salary arrears and security threats in 2013. By March 2014 the GoCAR had accumulated five months of arrears in addition to fifteen months of unpaid pensions and suppliers’ invoices, creating a major disruption (absenteeism) in the provision of public services, due to weak motivation on the part of civil servants (World Bank 2020). Through support from the World Bank, arrears were cleared and civil servants steadily returned to their posts where the security allowed. During this time, and after, the GoCAR also focused on enhancing the management of its payroll and made efforts to control attendance. The GoCAR has made important strides in consolidating its payroll management system. The payroll has been consistently audited since salary arrears were cleared in 2014. Moreover, the monthly process for the payment of the payroll has been made faster and more reliable as the payroll management system GIRAFFE has been made to directly connect to commercial banks. Last, mobile payments have been instituted as an option for civil servants who are paid through the participating commercial banks and agree to sign up. Current context The GoCAR’s HR and payroll management systems are disjointed and have consistently been updated at different paces, resulting in significant information asymmetries. The update of HR information on the payroll system has been in GoCAR’s reform agenda since 2013. At the time, new civil servant recruits were being added to the payroll without inputting their information on the HR database, leading to a 16.9 percent increase in payroll between January and December 2013. An update of the HR information was rolled out at the time of clearing the salary arrears of 2013, but the information was not kept updated. Advances have been slow—mainly because the HR system is a disorderly accumulation of civil servant’s career information held in physical dossiers at the Ministry of Civil Service (Minister du Function Publique) with no reliable process for consistent updates. Consequently, the “interconnection of systems” has been done by updating as much information possible on the payroll management system GIRAFFE. The payroll and HR systems are completely centralized, causing absences from posts whenever civil servants need any administrative HR service. No remote access to the systems has been developed and most modifications or additions to the information must be done through in-person requests in Bangui. This causes an obligation for civil servants to have to leave their posts and go to Bangui whenever any administrative issue arises. Note that formally the regional representations of the respective ministries (for example, the District Offices for Health) 46 47 should be the recipient of said requests, which they would then forward to Bangui for processing. Notwithstanding, 2. Select and bring to maturity a domestically owned pilot infrastructure project. civil servants have little trust in this system34 and prefer to travel to Bangui to make sure the issues are resolved. The GoCAR needs to carry out pilot infrastructure projects in the respective sectors using the domestic Importantly the systems fail to provide any nuanced approach or incentives to posting civil servants outside of public investment and procurement systems. This would develop a space to learn and enhance capabilities Bangui. Many of these outside postings are in underserved areas, with no access to electricity, running water, and fundamental to a sound PIM system. The sector ministries would work with the MEPC with the explicit goal of other public services, and have constant security threats. Civil servants hence have a clear preference for posting carrying forward certain pilot infrastructure projects. Innovative financing models could be explored, including in Bangui or close to it. There is no incentive structure developed to address this justifiable preference, which one in which external funds are used but the use of local systems is required. Importantly, the pilot would require partly drives absenteeism outside of Bangui. The civil servants with postings outside of Bangui are supervised by the involvement of each stage of the local systems and test their readiness for carrying out larger infrastructure the respective ministry’s deconcentrated departments, that is, health districts and school inspectorates, as well projects. as the prefecture offices. Health districts, school inspectorates, and prefectures are entitled to supervise civil servants’ performance, including attendance, and to report back to their respective human resources. However, 3. Select and fully train over the course of a year a class of civil servants involved in every step of the chain of the process through which an unjustified absence turns into a salary stoppage35 can take three to six months, procurement. while the respective public service suffers from the absence (for example, the children are not taught). The GoCAR should consider a sector-focused approach, where the whole chain of procurement for a specific Bottlenecks to service delivery sector is strengthened. Start with capacity building in the SPMPs of health and education and their respective resource management units. Then build capacity in the team within the DGMP that manages the sectors, and The combination of hyper-centralization of HR administrative capacity, lack of local payment capacity, and then the team at ARMP that would review the sectors. The objective would be to make sure that each step of the lack of incentives to work outside of Bangui, causes absenteeism affecting the quality of education and health procurement chain works, but by intervening in sectors instead of trying to strengthen the whole system, at first. services outside of Bangui. As explained in detail in the respective chapters, the quantity and capacity of human In addition, the capacity building interventions would also encourage enhancing the transparency of the process, resources outside of Bangui is a clear constraint to the quality of health and education services. These challenges prioritizing the publication of regulations, bids, and awards through the respective sectors networks. A milestone are all related to the overarching problems of (i) the absence of local payment capacity, which means civil servants to this approach would be the yearly procurement plans which, if done optimally would be submitted and reviewed have to go to Bangui, or the nearest Bank Agency which is usually many hours away, to collect their salaries; (ii) the and published during the budget approval phase, and not after, as it is now the case. These interventions would absence of an HR policy that rewards or recognizes civil servants appropriately when they are posted outside of be carried out with the dual objectives of (i) assuring compliance with the legal processes and (ii) enhancing the Bangui; and (iii) the absence of an HR system that can manage the long-term and short-term career performance transparency of the processes. of civil servants. This latter system would also need to have the ability to discern whether the civil servant is indeed in their post and react immediately if they are not. 4. Carry out a pilot procurement process outside of Bangui. Moreover, the absence of local payment capacity extends to the domestically financed SP sector, which The GoCAR should consider pilot procurement processes to be carried out by regional deconcentrated entities, continues to use antiquated payment systems. For example, the higher education scholarships, which amount outside of Bangui. Developing the capacity for regional authorities (such as prefectures) and/or sectoral to about half of nationally funded SSN programs, are paid in cash in Bangui in the respective university using a list deconcentrated entities (such as health district authorities) to carry out procurement processes should be a of beneficiaries. The rest of the cash transfers program uses costly mechanisms, financed by external donors, to priority as it could have considerable economic impact in the relevant localities. A way to start would be to select reach areas outside of Bangui. This means, if the domestically financed SP system were to expand, the payment one or two prefectures for a pilot program where civil servants are trained and closely monitored by either the system would need to be updated to be able to extend to areas outside of Bangui. sectoral procurement units, the DGMP, or the ARMP. 5. Develop a fiscally sustainable HR policy that incentivizes taking up postings outside of Bangui. 3.7. RECOMMENDATIONS The GoCAR needs to develop an HR policy that will create incentives for health and education workers to accept and complete postings outside of Bangui effectively. This means developing a policy that builds an incentive 1. Influence the central budget preparation process through budget evaluation and budget policy papers. structure that considers financial and non-financial benefits. These could include limiting postings outside of Bangui to three years of service with the assurance that after these three years the civil servant will be offered The GoCAR needs to strengthen the social ministries’ capacity to evaluate the effectiveness of their own budgets a different, possibly easier, posting. It can also include diminishing the hardship conditions through low-cost and prepare budget proposals that include the learnings from these evaluations. As discussed in previous chapters services, such as relocation campaigns, where civil servants are offered transportation to and from their posting the sectoral budgetary allocation needs to be improved, as well as the allocation of expenditures within sectors. (or a central location near it) twice a year. Each sector should develop a policy appropriate to the situation of their In order to do this, the ministries must present the technical cases for such changes at the budget hearings, workers, but they will need to work with the MFB and MEPC to ascertain the fiscal sustainability of the policy. along with their respective procurement plans. The GoCAR must ensure that the ministries have the capacity to present these cases by developing the right capabilities in the respective ministries. This could be accomplished 6. Set up an effective human resource management information system (HRMIS), an attendance records by charging the MEPC with improving sectoral planning capabilities.36 system, and HR administrative hubs outside of Bangui. For the above policy to be implementable the GoCAR needs to develop first an HRMIS and an effective attendance records system. In order to manage the long-term performance of civil servants strategically, the respective ministries must first be able to manage details of the career track record of their health and education workers. For this an HRMIS needs to be developed, and this system needs to have a connection to the salary payment 34  Arguably justifiably, as the processes by which the regional offices would represent the civil servant are not clear. system GIRAFFE. Once this system is developed, and the policy above is rolled out, the ministries must have a 35  The process can take many forms, but they all include a local supervisor informing the central unit (in Bangui) of an unjustified absence and the central unit eventually contacting the MFB’s Payroll Directorate (Direction de Solde) to stop payments. In its longest form, the Prefect method to ascertain attendance outside of Bangui and, crucially, to immediately react through the sanctions will report to the respective ministry’s Resources Management Directorate (Direction de Gestion des Resources) of the civil servant’s absence, presented in the policy (for example, suspension of salary). which will in turn submit the claim to their local inspectors for corroboration, and once/if corroborated the Directorate will inform the Wage Bill Directorate. According the one of the Prefects this process can take from three to six months, as the central Directorates take their time in responding to the claims, which are made in the form of an official letter transported to the central unit. Importantly, the Prefect stated that all In addition, the HR system created needs to have a deconcentrated capability, that is, the information can be civil servants who have gone through salary stoppage have immediately reported back to work. modified by the appropriate entities outside of Bangui. The deconcentrated units of the respective ministry— 48 36  Indeed, the MEPC has already been carrying out trainings on Sectoral Planning. 49 such as the health district, education inspectorate, or protectorate offices—need to have access to the HR system, Proposed reforms Time frame Action: What to do concretely Expected impact Institutions thus allowing civil servants to carry out HR administrative procedures on location. As such, development of the system needs to account for the limited infrastructure and capacities outside of Bangui. Develop an HR policy Short to • Select a policy lead for the • Increased • Ministry of Health that will create medium education and health ministries recruitment and and Education’s policy 7. Explore payment solutions at the location of service delivery, including, but not limited to, mobile payments. incentives for health term and a focal point at the Civil Service permanence in leads and education Ministry. posts outside of • Ministry of Civil Last, the issue of local payment capacity needs to be addressed through innovative methods, including, but not workers to accept and • Prepare series of actions that Bangui Service limited to, mobile payments. Mobile payment systems for salaries could also be extended to other payments, complete postings could be included on the policy outside of Bangui and delineate how these will be such as those related to SP. However, the introduction of mobile payments of government salaries and benefits effectively. evaluated. needs to be accompanied by a broader national policy for the development of a mobile payments economy. That is, the roll out of mobile payment of salaries needs to think through how civil servants and beneficiaries will turn Develop an HRMIS Short to • Create a working group to lead the • Effectively • Ministries of the payment into actual consumption in their communities when/if suppliers in the community don’t use mobile and an effective medium development of the HR system and manage civil Education and Health attendance records term establish a work program. servants’ long- • Ministry of Civil payments. This entails both thinking through the cash-out methods, but also other measures to incentivize cash- system in human • Ensure the system is operationally term careers Service in from agents other than civil servants, such as the mobile payment of public services such as electricity. In capital development linked with the payroll system and • ONI addition, the GoCAR needs to carry out a more active exploration of the establishment of new bank agencies sectors. any discrepancies are documented outside of Bangui.37 and addressed. Local payment Short to • Create a working group to select • Increase access • Ministries of capacity needs to be medium and lead the initiatives of local to salary Education and Health TABLE 3.1. PROPOSED REFORMS addressed through term payments to health and education payments • Ministry of Finance innovative methods, workers. Delineate possible outside of Bangui and Budget including, but not solutions and how these will Proposed reforms Time frame Action: What to do concretely Expected impact Institutions limited to, mobile be evaluated. Prepare working payments. program. Strengthen the Short to • Prepare a learning program for the • A higher and • Social Sector social ministries’ medium respective units with the aim of more efficient Ministries -Resources capacity to evaluate term developing a budget policy paper by budgetary Management the effectiveness of their own budgets the time of the first budget hearing of 2022. allocation for the respective Directorate • Ministry of Economy REFERENCES and prepare budget • Involve the MEPC in the learning ministries and Plan—Economic proposals that include program, especially the modules based on sound Programming 2AC. 2020. “Evaluation Des Marchés Publics En République Centrafricaine.” the learnings from related to sectoral planning. technical inputs. Directorate these evaluations. ———. 2021. “Évaluation de La Gestion Des Investissements Publics En République Centrafricaine. Diagnostic Basé Sur La Méthodologie PIMA.” Carry out pilot Short to • Each ministry selects an • The units • Human Development République Centrafricaine. 2018. “Rapport Exécution Budgétaire Quatrième Trimestre 2017.” Ministère des infrastructure medium infrastructure project proposal to involved in the Ministries -Resources Finances et du Budget. Direction de Cabinet. Direction General du Budget. République Centrafricaine, Bangui. projects in the term be presented in the 2022 budget process will gain Management respective sectors hearings. This project proposal will the know how Directorate ———. 2020. “Programme Triennal d’Investissement 2018–2020.” Ministère de l’Économie, du Plan et de using the domestic be carried to maturity with the needed to carry • Ministry of Economy la Coopération. Direction de Cabinet. Direction Générale de la Programmation Economique. République public investment and support of the MEPC, by the time of through other and Plan —Economic procurement systems. the 2022 budget hearings. infrastructure Programming Centrafricaine, Bangui. projects. Directorate World Bank. 2018. “Implementation Completion and Results Report for the CF-Emergency Public Services Response Project.” 2018. http://documents1.worldbank.org/curated/en/166461530820036058/pdf/ICR-P149884- Strengthen the Short to • Select a group of individuals in • Train civil • Ministry of Health and OPCS-edited-06282018.pdf. procurement chain medium the ministries’ DPMPs, the DGMP, servants to carry Education’s DPMPs with a sector-focused term and the ARMP that will over out effective • DGMP and ARMP ———. 2020. “Aide Memoire de la Mission de Revue à Mi-Parcours et Appui à La Mise En Œuvre Du Projet.” approach. the course of one year receive procurement • ENAM targeted trainings on procurement processes. processing. The training will have • The 2023 budget the explicit objective of preparing will be informed the respective procurement plans by the respective by the date of the first budget procurement hearing in 2022. plans. • Develop a procurement process training curriculum through the ENAM. 37  For example, the National Strategy for the Restauration of State Authority (Stratégie Nationale de Restauration de l’Authorité de l’Etat en centrafrique) proposed establishing bank agencies within the United Nations Multidimensional Integrated Stabilization Mission in the Central 50 African Republic (MINUSCA) bases outside of Bangui as a way to ensure their security. The initiative was never followed through. 51 CHAPTER 4. EDUCATION38 38  The authors of the education chapter are Cristelle Kouame and Pierre-Emmanuel Couralet. Boubakar Lompo, Aristide Elysee Houndetoungan and Oulimata Ndiaye provided valuable contributions. 52 53 4.1. INTRODUCTION three levels corresponding to the bachelors-masters-doctorate (Licence Master Doctorat—LMD) degrees: these programs last three, two, and three years respectively. Both secondary and higher education include technical and This chapter provides an overview of spending in CAR’s education sector; analyzes the adequacy, efficiency, vocational education and training (TVET). and equity of public spending in the sector; assesses teacher management; and provides recommendations to Total student enrollment in both public and private schools stood at 1.4 million in 2018–19 out of a population of improve alignment of spending with sector needs. The chapter reviews the key characteristics and challenges around 4.7 million,39 with a median student age of 17. The private sector plays a significant role and accounts for of the education sector and its financing, with a focus on levels, sources, composition, and allocation, to derive 18 percent of total student enrollment. As shown in table 4.1, private schools represented 67 percent of enrollment recommendations on how to increase the adequacy, sustainability, and efficiency of education spending, which is at the preschool level, 15 percent at the primary level, 29 percent in secondary general education, 12 percent in critical to rebuild the sector. The analysis and recommendations build on the recent Education Sector Plan (ESP) secondary TVET, and 21 percent in HER. 2020–2029 (MPSE, MPSTA, MSRTI, and MES 2020). This chapter is structured into five sections which provide: (i) an overview of the education system including sectoral goals and policies; (ii) an analysis of education sector financing in CAR, with special attention to adequacy, TABLE 4.1. STUDENT ENROLLMENT IN CAR, 2018–19 efficiency, and equity considerations; (iii) an assessment of challenges with teacher management and strategic priorities for managerial improvement; (iv) a synopsis of financing needs and sustainability of education spending, N % Private % Girls and (v) recommendations. The analysis in this chapter focuses on actual government spending, and specifically Preschool 36,943 67% 51% spending of the four ministries of education. Lastly, data used for this chapter as well as their limitations are detailed in Appendix A1.5. Primary 1,168,377 15% 44% Secondary (excluding TVET) 170,139 29% 37% 4.2. OVERVIEW OF THE EDUCATION SYSTEM Secondary (TVET) 6,061 12% 24% HER 16,450 21% 36% 4.2.1. Sectoral Goals and Priorities Total 1,397,970 18% 43% CAR’s RCPCA-CEM 2017–2023 acknowledges education as a national priority and emphasizes its importance for renewing the social contract between the state and the population. Improving the provision of education, a Source: EMIS 2018–19. critical determinant of the quality of human capital, aligns with the government’s objectives for fostering social cohesion and peacebuilding through the provision of basic services throughout the territory. The government’s vision for the education sector, derived from the RCPCA, is that all communities should have access to quality education, which will contribute to reducing regional disparities, identified as one of the root causes of conflict. EDUCATION ADMINISTRATION The government plans to achieve this through the implementation of the Education Sector Plan (ESP) 2020– 2029, adopted in May 2020. CAR’s education system was the responsibility of four ministries of education until June 2021. The Ministry of Primary and Secondary Education (MPSE) is responsible for preschool, primary, and secondary education; the The primary goal of the ESP 2020–2029 is to rebuild the education system and contribute to the development of Ministry of Technical Education and Literacy (MTEL) for technical and vocational education and training, including a human capital that is productive and able to bring strong, inclusive, and sustainable growth. More specifically, literacy; and the ministries of Higher Education (MHE) and Scientific Research and Technological Innovation the ESP is structured around four strategic axes: (i) increase equitable access to education and training; (ii) train, (MSRTI) are both responsible for the tertiary sector. Following recent formation of the new Central African recruit, and deploy a large number of teachers throughout the country; (iii) improve the quality of education; and government on June 23, 2021, the sector is now managed by two ministries: (i) the Ministry of National Education, (iv) reform sector governance and increase funding for the education system (see figure A1.1 in Appendix A1.1). which is the fusion of MPSE and MTEL; and (ii) the Ministry of Higher Education and Research, which is the fusion of MHE and MSRTI. Challenges related to the implementation of the ESP have been exacerbated by the COVID-19 pandemic and elections turmoil in 2020 and early 2021. The government’s commitment for the first year of the plan has not Eight other ministries as well as the Presidency of the Republic finance education activities until June 2021. The been realized. First, the ESP has not received near its budget requirements. Budget allocation to the education supervision of preschool education is shared between MPSE and the Ministry for the Advancement of Women’s sector (as a percentage of total government spending) was expected to increase from 13.3 percent in 2019 to and Children’s Affairs (Ministère de la Promotion de la Femme de la Famille et de la Protection de l’Enfant— 15.8 percent in 2021. Second, authorities were not able to implement key reforms related to teachers that were MPFFPE), which currently is the main provider of early childhood education. Vocational education is provided by envisioned to begin in the 2020–21 school year. several other ministries, including the Ministry of Labor, Employment, Training and Social Protection (Ministre du Travail, de l’Emploi et de la Protection Sociale et de la Formation Professionnelle—MTEFPS) and the Office of the President of the Republic (in charge of the supervision of National Pioneer Youth centers). Lastly, education and 4.2.2. Organization of the education system training in agriculture are under the mandate of both the Ministry of Agriculture and Rural Development and the Ministry of Livestock and Animal Health. EDUCATIONAL OFFER The administration structure of CAR’s education system is organized into three levels: central, regional, and CAR’s formal education system uses a 3-6-4-3 structure from preschool education to the end of secondary school levels. The central level (that is, the ministry level) is responsible for policy making and the overall strategic education (see figure A1.2 in Appendix A1.1). Preschool education is offered for three years to children 3–5 coordination of the education sector. The second level is the regional level; it implements policies and coordinate years old. Basic education spans 10 years and is divided into 6 grades for primary education and 4 grades for education services. MPSE is the only ministry that has a deconcentrated governance structure with regional lower secondary. Primary and lower secondary education are classified as universal education (enseignement fondamental, F1 and F2) and cover ages 6–15. Three years of upper-secondary education follow, leading to the Upper Secondary Education Certificate (Baccaulauréat). Higher education and research (HER) is divided into 54 39  As per World Population Prospects 2019 revision. 55 management units called school inspectorates (SI). There are in total 8 SI broken down into 21 school districts ACCESS AND EQUITY OF ACCESS TO EDUCATION (circonscriptions scolaires) and 104 school subdistricts (secteurs scolaires). Each SI supervises in-service teacher training, inspection of primary and secondary schools, provision of textbooks, and school supplies. Lastly, schools As of 2019, access to education remains inequitable and limited at all levels of education, with poorer children, are found at the third level and are responsible for delivering and coordinating teaching and learning services, as girls, and students living outside of Bangui areas especially affected. The GER stood at 117 percent at the primary well as responsible for the maintenance of school buildings. level, but only 9 percent at the pre-primary, 31 percent at the secondary (including TVET), and 3 percent at the higher education level (including TVET) (see figure 4.2). Access is lower among girls, children living outside Bangui Metropolitan Area (BMA), and children from poorer households. Girls register a lower GER at all levels of education 4.2.3. Key education performance indicators (for example, 109 percent at the primary level in comparison to 124 for boys; see figure 4.2). Children living in BMA register a GER of 141 percent at the primary level as opposed to 113 percent in the other regions of the country. HISTORICAL CONTEXT Furthermore, the gap in access to education between children from the poorest quintile and richest quintile is wide and increases with each level of education—the GER is 9 percent for the poorest and 83 percent for the CAR has made some progress in ensuring access to education for all school-age children and adolescents since richest quintile at the lower secondary level. 2000. Estimates from the Multi Indicator Cluster Surveys (MICS) show that the gross enrollment rate (GER) at the primary level stood at 72 percent in 2000 and increased to 109 percent in 2010 and to 117 percent in 2019 (see figure 4.1). However high GER rates in 2019 do not reflect universal access to primary education, but rather FIGURE 4.2. GER BY LEVEL OF EDUCATION, GENDER, AND AREA OF RESIDENCE high repetition rates, delayed entry, and a large proportion of over-age children (see section 4.2.3). At the lower secondary level, improvements have been much weaker with a GER increase from 11 percent in 2000 to 37 percent 150% in 2019, reflecting low transition from primary education to lower secondary. Finally, there has been a reduction of the out-of-school rate among students ages 6–11, from 56 percent in 2000 to 33 percent in 2010 and to 26 141% 138% percent in 2019. 125% 124% 117% 113% FIGURE 4.1. GER TRENDS BY LEVEL OF EDUCATION AND OUT-OF-SCHOOL RATES AMONG 109% 100% STUDENTS AGES 6–11 SINCE 2000 100% 93% OUT-OF-SCHOOL RATES, 6–11 YEARS OLD (%) 120% 60% 75% 56% 74% 117% 100% 109% 50% LEVEL OF EDUCATION (%) 59% 50% 80% 89% 40% 72% 38% 60% 30% 34% 34% 26% 25% 31% 10% 24% 9% 9% 40% 20% 6% 7% 3% 3% 3% 3% 39% 2% 0% 11% 0% 20% 30% 10% 0% 20% TOTAL Girls Boys BMA REST RCA Q5 (wealthiest) Q1 (poorest) 11% Pre-primary Primary Secondary (incl. TVET) Tertiary (incl. TVET) 0% 0% 2000 2006 2010 2019 GER at primary GER at lower secondary Out of school rate Sources: MICS 2019, authors’ calculation. Sources: MICS 2019 (authors’ calculation); MICS 2000, 2006, 2010 (CAR EBESP project appraisal document). Approximately half a million children and youth ages 6–18 in CAR are not in school, with girls being the most disadvantaged. As shown in table 4.1, about 26 percent of children ages 6–11, 24 percent of those ages 12–15, and CAR’s limited progress over the past 20 years can be explained by the multiple and prolonged periods of conflict 49 percent of youth ages 16–18 were out of school in 2019. The incidence of being out-of-school tends to be higher that have further weakened an already low-performing education system. Since gaining its independence, CAR among girls than boys across all age groups.41 As highlighted in the Skills Training and Youth Employability ASA has completed just two peaceful transitions of power, one in 1993 and one in 2016. The country’s most recent phase II (P171903), these high out-of-school rates could be explained by the following factors: (i) the prolonged major conflict began in early 2013, leading to the formal system ceasing to function for two years in most regions periods of conflict, which have resulted in the displacement of many children and youth and a large number of of the country. In 2020, the COVID-19 pandemic led to the closure of schools from March 2020 until the start of refugees (see above); (ii) the supply and demand-side constraints linked to accessing education (see below); (iii) the school year in October 2020; and a few weeks after returning to school, learning was again interrupted by the poor quality of education as reflected by high repetition rates, large proportion of overaged students, and low pre- and post-election unrests in late 2020. Many schools were forcibly shuttered, occupied, or damaged in 11 out returns of education (see below); and more recently (iv) school closures due to the COVID-19 pandemic. of 16 of the country’s prefectures. As a result of these successive cycles of violence and conflict, CAR was not able to achieve the Millennium Development Goals in 2015 and is not on track to achieve the education targets of the Sustainable Development Goals in 2030 (SDG 4).40 40  Target 1 of SDG 4 states that “By 2030, ensure that all girls and boys complete free, equitable and quality primary and secondary education 41  Out-of-school rates are 30 percent for girls compared to 23 percent for boys among ages 6–11, 30 percent for girls compared to 18 percent 56 leading to relevant and effective learning outcomes.” See https://sustainabledevelopment.un.org/sdg4. for boys among ages 12–15, and 64 percent for girls compared to 33 percent for boys among ages 16–18. 57 TABLE 4.1. OUT-OF-SCHOOL CHILDREN AND YOUTH AGES 6–18, BY GENDER secondary levels—higher than most African countries such as Ghana (1.8 percent at primary) and Cameroon (12.1 percent at lower secondary).45 Dropout rates are also high and increase with each level of education, standing at 6 Age group Total Girls Boys percent, 12 percent and 15 percent at the primary, lower, and upper secondary levels, respectively.46 High repetition and dropout rates are largely attributable to (i) poor learning conditions as shown by high student-classroom 6-11 % 26% 30% 23% ratio (SCR); (ii) the relative high proportion of community teachers who are often unqualified with little or no pedagogical training; and (iii) unprepared children due to abysmal early childhood development and poor child N 210,780 119,152 91,628 health (see Chapter 5), including stunting and malnutrition (malnutrition is a major cause of absenteeism and 12-15 % 24% 30% 18% attention deficit in the classroom). N 125,765 78,419 47.346 As a result of the very low quality of education and long periods of school closure, a high proportion of Central African students are overage (figure 4.3). There are as many students age 16 (31 percent) enrolled in primary 16-18 % 49% 64% 33% school as in secondary school, whereas the official age to enter lower secondary is 12 years. This is an issue for both girls and boys; however, only 50 percent of girls are in school at age 16 (25 percent in primary and 25 percent N 164,565 107.659 56,906 in secondary) compared to 73 percent for boys (37 percent in primary and 36 percent in secondary). Being overage 6-18 % 29% 35% 23% contributes to having many children and youth out of school. N 501,110 305,230 195.881 FIGURE 4.3. SCHOOL STATUS, AGES 10–19, BY GENDER, ALL CAR Source: MICS 2019 and WPP 2019, authors’ calculation 90% In CAR, there is a mix of critical demand and supply-side constraints to accessing and completing basic education. 80% On the supply side, CAR has: (i) an insufficient number of schools and a huge deficit of classrooms at the primary 70% and secondary levels (see section 4.3.3); and (ii) a huge lack of qualified teachers, especially outside Bangui, which 60% proves to be a major bottleneck in terms of access to education (see section 4.4). On the demand side, there 50% are multidimensional barriers in accessing and completing basic education. Low enrollments, especially at post- 36.3% 40% primary, can be primarily explained by households’ financial constraints and low returns to education. Moreover, 30% 24.8% social and gender norms are unfavorable to girls’ schooling. Appendix A1.1 presents the detailed assessment on 20% these constraints. 10% 0% EDUCATIONAL OUTCOMES 10 11 12 13 14 15 16 17 18 19 10 11 12 13 14 15 16 17 18 19 GIRLS BOYS Primary school Secondary school Drop out Never attended Learning outcomes The quality of education, as measured by learning outcomes, is extremely poor. According to the 2006 CONFEMEN Sources: MICS 2019, authors’ calculation. Educational System Analysis Program (Programme d’Analyse des Systèmes Éducatifs de la CONFEMEN—PASEC42) assessment—the last regional assessment in which CAR participated—the country ranked the lowest, both in French and mathematics, among the 10 French-speaking African countries that participated, with scores of 23.8 Completion rates out of 100 in French and 28.8 out of 100 in mathematics.43 More recent results from the 2018–19 Early Grade Reading Assessment (EGRA) carried out in the Bangui SI provide evidence that learning outcomes are still very Completion rates are low at all levels of education, especially for girls and those living outside of BMA. As shown low;44 57 percent of students in grade 2, 41 percent in grade 3, and 20 percent in grade 4 could not read a single in figure 4.4, completion rates at all levels of education by gender (left) at primary and by area of residence (right) familiar word in one minute. The low test scores could reflect, in part, the near-total lack of understanding of indicate that only 42 percent of students ages 16–18 in CAR had completed primary education and only 6 percent the French language used for teaching (on the contrary, Sango is spoken by almost all Central Africans as franca of students ages 20–22 had completed secondary education. Only 34 percent of girls ages 16–18 had completed lingua). primary education and 13 percent of girls ages 20–22 had completed lower secondary education; completion rates stand respectively at 50 percent and 23 percent, respectively, for boys of the same age groups. Completion rates are even lower among students living outside Bangui, where only 31 percent of students ages 16–18 complete Repetition, dropout rates, and overage primary education compared to 77 percent of students living in Bangui. Compared to the average for SSA countries, High repetition and dropout rates are also reflective of a poor quality of education and result in a high completion rates in CAR are significantly lower. On average, only 59 percent of students in CAR complete primary proportion of overaged Central African students. Repetition rates were 21 percent at both primary and lower education as compared to 69 percent in the region; and secondary completion rates stood at 14 percent in CAR compared to 44 percent in SSA (2018).47 This leaves CAR significantly behind when it comes to progress toward the achievement of universal primary and secondary education. 42  CONFEMEN stands for Conférence des Ministres de l’Éducation des États et Gouvernements de la Francophonie (Conference of the Ministers of Education of Francophone Countries). 43  The average score of the 10 countries participating in this evaluation was 38.5 out of 100 in French and 40.5 out of 100 in mathematics. 44  The results of this test are only representative for the Bangui SI. However, as this SI is less disadvantaged than the rest of the country 45  Sources: Authors’ calculation based on EMIS 2018–2019 for CAR and UNESCO Institute of Statistics (UIS) for other countries. according to all the socioeconomic and educational indicators, the results of this EGRA test must be considered as an upper bound of the level 46  Source: Authors’ calculation based on MICS 2019. 58 in the other regions. 47  Figures based on data from EMIS 2018–2019 and UNESCO Institute for Statistics estimates. 59 FIGURE 4.4. COMPLETION RATES AT ALL EDUCATION LEVELS BY GENDER (LEFT) AT PRIMARY AND BY AREA OF RESIDENCE (RIGHT) 80% 80% 81.3% 77.1% 70% 70% 73.4% 60% 60% 50% 50% 50.4% 40% 40% 41.8% 40.6% 30% 30% 34.0% 30.5% 20% 20% 6.4% 8.7% 23.0% 21.2% 4.5% 17.6% 13.5% 10% 10% 0% 0% Primary Lower secondary Upper secondary Outside BMA BMA Total Girls Boys Sources: MICS 2019, authors’ calculation. Note: Completion rate calculated on age groups 2 years older than the official definition, that is, ages 16–18 instead of ages 14–16 for primary. Literacy rates and educational attainment of the labor force Literacy rates are extremely low among youth and many of them lack the basic skills needed to engage into productive labor market activities. As indicated in table 4.3, estimations based on MICS 2019 show that only approximately 24.9 percent of women ages 15–49 were able to read a simple and complete sentence compared to 47.5 percent of men in the same age group. Literacy rates are also low for the younger cohort (see table A1.1 in Appendix A1.1). The educational attainment of youth remains very low as per estimations based on the Enquête Nationale sur les Monographies Communales (ENMC) 2018. About 22 percent of the youth ages 15–24 had no formal education, only 44 percent had some primary education, and only about 1 percent had been beyond INSTITUTIONAL CHALLENGES AND SECTOR MANAGEMENT secondary education. Given these low educational attainments, the youth population will most likely lack basic skills in literacy and numeracy if this issue is left unaddressed. Institutional challenges TABLE 4.2. LITERACY RATES AMONG WOMEN AND MEN AGES 15–49, BY AREA OF RESIDENCE Governance of the education system is fragmented across several ministries and is too centralized to be effective in a large and sparsely populated country. The number of ministries in charge of education has changed six times   Women Men Ratio W/M from 2012 to 2021: three ministries in 2012–13, only one in 2014, two in 2015–16, again only one in 2017, three in 2018, four in 2019–20, and finally two since June 23, 2021. The 2019 Peace Agreement led to the formation of an Bangui Metrop Area 68.7% 81.9% 0.84 inclusive government, including different political affiliations and armed groups and a proliferation of ministries and central administrative structures. For example, there were two ministries (MES and MSRTI) responsible for Rest of CAR 13.2% 37.2% 0.35 higher education, research, and innovation in 2018–20. These subsectors are interdependent and concentrated Urban areas (-BMA) 33.4% 59.0% 0.57 in CAR’s only public university, the University of Bangui. In addition, MTEL hardly exercises supervision over the many players engaged in vocational education and training (see section 4.2.2). The lack of coordination between Rural areas 7.6% 30.4% 0.25 the various ministries and the private sector has been highlighted in the National Strategy for Technical Education and Vocational Training in the Central African Republic (SNETFP).48 Total 24.9% 47.5% 0.52 The fragmentation of the governance of the system has created duplication of roles with limited qualified Source: MICS 2019, authors’ calculations human resources (HR) to manage the sector and support schools. At the central level, until May 2020, all four Note: All persons with minimum lower secondary education are assumed to be literate ministries except MTEL were coordinated by one Permanent Secretary (Directeur de Cabinet). All four ministries also rely on the General Directorate for Studies, Statistics, and Planning (Direction générale des études, des statistiques et de la planification—DGESP), under the MPSE, to produce the Education Management Information 48  According to SNETPF, employers’ organizations “are not very active in the area of training, which accounts for one of the main weaknesses in the governance of the system” (AFD 2018: 7). “[T]here is neither a coordination entity between these different training centers nor dual 60 supervision with the ministry in charge of vocational education and training, as is the case in other countries” (AFD 2018: 31). 61 System (EMIS), rending the statistical units under the other ministries redundant. At the decentralized level, the FIGURE 4.5. TRENDS OF ACTUAL GOVERNMENT SPENDING ON EDUCATION, 2012–20 ESP highlighted (i) the lack of autonomy of SI in the management of the education system, in particular for the recruitment, monitoring, and supervision of teachers, and the organization of end-of-year exams;49 (ii) the lack 25% 30,000 of administrative buildings, which limits the implementation of monitoring and supervision activities of schools; and (iii) the unequal size of school districts and subdistricts, which range from 25–71 public primary schools per 20.9% 25,000 school subdistrict in the North SI to 3–10 in Bangui SI. 20% 20,000 Sector management challenges 15% 11.2% 11.7% 15,000 26,240 CAR’s current education sector management is weak and driven by critical constraints in teacher management 22,775 10% 21,676 and payment. First, HR management is inadequate and characterized by irregular pre-service training, absence of 25,148 18,716 10,000 17,333 regular and sustainable recruitment practices, and inefficient deployment (see section 3.4). Second, providing and 15,475 14,107 13,306 accessing salary payments remains a major challenge in CAR. While this later issue affects all public civil servants, 5% 2.1% 1.8% 5,000 teachers are among the most affected as many of them are posted in rural areas and must then travel long 1.1% distances to be able to receive their salaries in one of the provincial capitals with a bank (see section 3.4). Lastly, 0% 0 the EMIS is lacking critical data needed for decision making and geo-referencing of schools for infrastructure 2012 2013 2014 2015 2016 2017 2018 2019 2020 development. It relies on a questionnaire that is manually completed by school administrators, uses centralized Million CFAF (constant 2020) % of government spending % of GDP data entry, and lacks a system for quality control. Sources: Calculations based on data from the Ministry of Finance and Budget (Ges’Co 2012–20) and the World Economic Outlook (2020). The prolonged period of conflict has fragilized the government’s capacity to deliver education services, which Note: Expenditures are for the four ministries of education. contributed to poor management of the sector. Education service delivery in a FCV context tends to collapse in the event of crises or emergencies and takes a long time to recover. Even though the MPSE has had an emergency unit (Cellule d’Urgence) in place since 2017, there are no effective mechanisms to ensure continuity of education in case of emergencies and the system takes a long time to respond to the needs of the affected students. For example, 4.3.2. Financing sources following the flood in October 2019 in Bangui, temporary classrooms (Espaces temporaires d’apprentissage et Education funding comes from three main sources: (i) the government budget, (ii) external financing from de protection de l’enfant—ETAPE) were installed but only several weeks after the construction of the IDP camps. technical and financial partners (TFPs), and (iii) contributions from parents. Moreover, blackboards were still missing in most temporary classrooms as of March 3, 2020. The situation is still more complicated when emergencies occur outside Bangui. Government budget 4.3. EDUCATION SECTOR FINANCING The share of actual total government expenditure allocated to the ministries of education stood at about 12.7 percent on average during the period 2012–20,52 but it remains insufficient to address the sector needs. At least since 2015, more than half of public primary teachers are community teachers53 and are not paid by 4.3.1. Education spending the government budget, but by households or TFPs. Furthermore, funds are budgeted to provide schools with learning materials via SI, which are in turn responsible for dispatching these materials to schools. However, these The share of actual government expenditure allocated to education stood at 11.7 percent in 2020 and has funds are both insufficient and not always executed, especially for schools that are outside major cities. Evidence increased by only 0.5 percentage points since 2012. As shown in figure 4.5, actual government spending on collected from field visits conducted during the elaboration of the ESP and consultations held with MPSE officials education as per the four ministries directly in charge of the sector represented 11.2 percent of total government indicate that most schools do not receive operating funds and lack the basic teaching and learning materials, and spending in 2012 (CFAF 13,644 million; US$25.2 million), reaching 20.9 percent in 2017 (CFAF 24,700 million; sometimes even the school furniture, to function adequately. US$45.5 million) and falling to 11.7 percent in 2020 (CFAF 25,148 million; US$46.4 million).50 During the same period, government spending as a proportion of GDP remained below 2 percent on average. Besides these ministries, there are also eight other ministries and the Presidency of the Republic that engage in education activities (see Technical and financial partners: project grants, credits, and budget support section 4.2.2). Spending on education as per these entities represented CFAF 370 million on average in absolute The actual share of total education sector external financing and the total education budget are low in terms, equivalent to about 0.3 percent of total government expenditure, between 2012 and 2017. However, from comparison to other sectors—transport, SP, and gender. As shown in figure 4.6, the actual share of total external 2018 onwards, these additional education expenditures increased sharply to reach CFAF 3,201 million (or 2.4 financing (the sum of project grants and credits) allocated to the education sector stood at 1.6 percent in 2018, 4.4 percent of total government expenditure) in 2018 and CFAF 2,727 million in 2019. This sharp increase is entirely percent in 2019, and 5.4 percent in 2020. This share is very low compared to the transport sector (25.8 percent), and due to the expenditures of the Ministry of Security, Immigration and Public Order.51 lower than the health sector share (7.9 percent). External financing as a proportion of total actual public spending on education increased from 4.9 percent in 2018 to 11.9 percent in 2019 to 18.2 percent in 2020 (see table A1.2 in Appendix A1.1).54 The focus of TFP support was largely on school construction and rehabilitation, teacher training, 49  Discussions with School Inspectorate (IA) officials in December 2019 highlighted the fact that the current organization is very much and quality improvements in general, with a strong focus on primary education (see table A1.3 in Appendix A1.1). By centralized: exam papers are prepared in Bangui but are marked at the IA (except for the baccalauréat exam). 50  The implementation of the CAR RCPCA-CEM could explain the sharp increase in total public spending (including in education) in 2017 compared to previous years. In November 2017, the government convened a donor conference in Brussels where CAR’s technical and financial partners (TFPs) pledged US$1,700 million for the 2017–19 period, out of which 43 percent had been disbursed in June 2019 (IMF 2020). 51  This spending amounted to CFAF 2,858 million and CFAF 2,400 million in 2018 and 2019, respectively, whereas they had never exceeded CFAF 52  This excludes allocation to the sector in 2017 (20.3 percent), which is an outlier, considering that allocation to the education sector has never 350 million before. The spending was mainly intended for the Police Academy and the Gendarmerie Academy in order to train more officers to exceeded 14.9 percent since 2012. strengthen security. Such funds were earmarked for school operation and student scholarships; the highest expenditures included food (CFAF 53  Based on EMIS, 53 percent of primary teachers were community teachers in 2015–16 and this proportion grew to 58 percent in 2018–19. 630 million in the Police Academy and CFAF 830 million in the Gendarmerie Academy) and clothing (CFAF 300 million in the Police Academy and 54  These patterns can be explained by the delay in implementation of the Emergency Basic Education Support Project (EBESP) in 2018, and the 62 CFAF 430 million in the Gendarmerie Academy). However, these expenditures were very low (or even nonexistent) before 2016. COVID-19 pandemic, which led to additional emergency funds for the system. 63 comparison, in 2018 CAR stood below the average for SSA countries (4.9 versus 9.2 percent) and below the average 4.3.3. Adequacy of spending for low-income countries (12.1 percent).55 Finally, although TFP funding is useful to fill gaps in public spending, it is often volatile and unreliable; for example, it completely disappeared in 2013 due the political crisis. The adequacy of the education sector financing in CAR is measured based on the following key parameters: (i) government spending on education as a share of GDP and total government spending compared with the recommended benchmark; (ii) availability of government-paid teachers (further discussed in section 4.4); and (iii) FIGURE 4.6. DISBURSED EXTERNAL FINANCING—PROJECT GRANTS AND CREDITS, 2018–20 classroom and textbooks availability. Budget allocation to the education sector 2020 Government spending on education as a share of total government spending is below recommended levels for countries that have not yet achieved universal primary education (Bruns et al. 2003). As per GPE 2019 recommendations, such countries should allocate 20 percent of government spending to the education sector, but CAR’s government devoted only 13.3 percent on average over the period 2018–20. In comparison, the SSA average is 17.8 percent and countries such as Burundi, Kenya, Senegal, and Burkina Faso allocated between 19 and 2018 23 percent of their total government spending to education. Government spending on education in CAR is also very low in comparison to other SSA countries as a share of GDP; it was 1.7 percent of GDP on average over the 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% period 2018–20, whereas the average for SSA is of 4.6 percent (see figure 4.7). Education Health SP & gender Housing, environment, leisures Economic affairs General pub.services Defense & public order FIGURE 4.7. ACTUAL GOVERNMENT SPENDING ON EDUCATION CAR AND COMPARATORS, Source: Authors’ calculations based on data from the MoEPC. 2018–20 In addition to project grants and credits, TFPs also provide the education system with indirect financing Burkina Faso 22.7% 6.0% via budget support. Indeed, most of the budget support directly paid to the government through the MFB is 21.5% Senegal conditional on specific indicators, some of which are linked to the education system and intended to support 4.7% Burundi 19.9% reforms. This is the case of the budget support56 from the World Bank and the European Union. The World Bank 5.0% series of DPFs supports reforms on teacher recruitment and deployment. Over the 2018–19 period, budget support Kenya 19.1% 5.3% was conditional on the adoption of a ministerial decree to decentralize teacher recruitment at the SI level for the 17.8% Sub-saharan Africa next five years. For the period 2021–22, budget support will be conditional on establishing a national registry of 4.6% all graduate student-teachers (see Appendix A1.1). The European Union’s budget support for the period 2017–19 Benin 17.7% 4.0% was also conditional on six triggers related to the education sector (see Appendix A1.1). However, it should be 16.6% CEMAC (excluding CAR) noted that these indicators are related to governance reforms and then do not involve large government funding 3.0% Gambia 11.2% commitments; they therefore do little to increase education funding. 2.4% Rwanda 10.8% 3.1% Household financing Central African Republic (*) 13.3% 1.7% Liberia 8.1% While there are no estimates of household financing in the country’s education system, the high proportion of 2.6% community teachers and near absence of school operating funds suggest it is significant. The recent household 0% 5% 10% 15% 20% 25% surveys (see Appendix A1.3) do not provide information on the education expenditures of households, which is % of total government spending % of GDP a serious constraint that should be addressed in future surveys.57 Parents cover not only direct costs such as tuition fees, school operating costs, and basic materials, but also indirect costs such as transportation and Sources: Ministry of Finance and Budget (2018–20) for CAR and World Development Indicators (accessed 10/2021) for other countries. accommodation, which could be especially high in a low-density country such as CAR. Furthermore, in practice Note: Numbers for CAR are averages between 2018 and 2020. a significant proportion of primary schools operate as community schools, given that the government does not provide funds to pay for operating costs and the remuneration of community teachers. Since the beginning of the Despite education being a stated government priority, as stipulated in the RCPCA-CEM, CAR devotes only half COVID-19 pandemic, parents have also started paying for the salaries of secondary temporary teachers in areas as much of its budget on education as on defense and public order spending. Based on the classification of outside Bangui (see section 4.4). Finally, a significant proportion of students are enrolled in private schools (see spending by ministry,58 the level of public spending on defense and public order stood at 28 percent over the Table 4.1.) that do not receive any subsidies from the government. last two years (2019–20) in comparison to 21.4 percent for social sectors, of which only 11.9 percent for education (see figure 4.8). This inter-ministerial spending distribution raises concerns, given that the current allocation to the education sector is not enough to match its needs. Instead, the burden of funding for schooling is shifted onto extremely poor households. Given that household financing for community schools and private schools is 55  Estimates for the SSA and LIC averages are based on UIS 2018 data. probably at its peak (see section 4.3.2), government spending on education should increase. 56  However, it should be noted that the budget support from the Agence française de développement (AFD) is not conditional on specific indicators. According to an AFD expert, the agency suggested allocating almost all of the €10 million granted for 2019 (€9.7 million) to salaries and pension arrears, and €300,000 to audits of public entities. 57  As part of the upcoming Human Capital and Women and Girls empowerment project (P171158), a study on tuition fees will be carried out and 58  Appendix A1.2 presents the five broad categories: social sectors, defense and public order, economic affairs, general public services, and others 64 this should provide some information about financing by families. (environment, housing, culture, justice, youth and sport). 65 FIGURE 4.8. ACTUAL GOVERNMENT SPENDING BY SECTOR, AVERAGE 2019–20 schools, on average. Moreover, many students travel long distances to reach the nearest primary school and even longer to reach secondary schools. Salary Inadequate production and distribution of textbooks spending CAR faces serious challenges with textbook availability and distribution to schools. CAR has difficulty in Total providing schools with the minimum quantity of textbooks necessary for instruction. Officially, primary schools spending should be provided with textbooks so that each student has three textbooks (reading, math, and biology) and one history and geography (HG) textbook is available per two students. However, textbook-to-student ratios at 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% the primary level are above the national official ratios, averaging 1:2 for reading and mathematics textbooks. In Education Health Social Protection Others (*) grade 6, the ratio is high and reaches 1:15 for history and geography textbooks and 1:46 for biology textbooks. Economic affairs General Public Services Defense and public order As shown in figure 4.9 below, CAR stands at the same level as the SSA average for reading (1:2) and below for mathematics (1:3) textbooks. Furthermore, there are also challenges with distribution of textbooks to schools. In Source: Authors’ calculations based on data from the MoEPC 2019, 365,660 textbooks were acquired at a high cost, but they were not yet disseminated to schools as of May (*) Justice, youth and sports, environment, housing, and culture 2020. An appropriate textbook policy to ensure adequate distribution, conservation, and storage of textbooks to schools across the country especially in remote areas, has not been defined yet. An international comparison of government spending per student59 as a share of GDP per capita indicates that CAR spends less than the average for SSA at both primary and secondary levels. As shown in table 4.4, CAR spends 3.5 percent of GDP per capita (CFAF 9,140) on each student at the primary level, which is a third lower of the SSA FIGURE 4.9. RATIOS OF STUDENTS TO TEXTBOOKS AT THE PRIMARY EDUCATION LEVEL average (11.7 percent), and it spends 7.2 percent of GDP per capita on each student at the secondary level, which is far below the SSA average (22.1 percent). However, at the tertiary level, public spending amounts to 189.9 percent 14 of GDP per capita, which is above the SSA average of 132.3 percent. 14 12 11.96 TABLE 4.4. GOVERNMENT SPENDING PER STUDENT BY LEVEL OF EDUCATION, CAR AND 10 COMPARATORS, 2019 8   Per student spending Per student spending (% of GDP pc) 6   CFAF As a multiple of spending on primary CAR SSA average LIC average 5.58 4 5 Preschool 985 0.1 0.4% n.a n.a 1.39 0.90 2 1.04 0.85 3 0.35 2 2 2 Primary 9,140 1.0 3.5% 11.7% 10.3% 1.46 2 2 1 1 1 1 - Mali Burkina Niger Rwanda Congo, Dem. Burundi Central SSA Chad Cameroon Secondary (excluding TVET) 18,954 2.1 7.2% 22.1% 23.2% Faso Rep. African Rep. Reading Mathematics Secondary (TVET) 20,098 2.2 7.6% n.a n.a HER 501,908 54.9 189.9% 132.3% 171.5% Source: Edstat consulted in May 2021. Source: Calculations based on data from the Ministry of Finance and Budget (Ges’Co 2019) and EMIS 2018–19 for CAR; Edtast for SSA and LIC average (2012–15). Unit costs of textbooks purchased by CAR are high compared to international benchmarks, suggesting Note: Preschool enrollment and spending include those of the MPFFPE. inadequacy of spending on textbooks. In 2018 and 2019, textbooks acquisition amounted to CFAF 2.245 billion (or US$3.8 million), at an overall cost per textbook ranging from US$7 to US$9. In projects funded by USAID or the World Bank (Mozambique, Liberia, Mali, Kenya, and so forth), the unit cost (including distribution) was always Inadequacy in the provision of schools and classrooms below US$1.5, often close to US$1.61 The high costs of textbooks in CAR can be explained by the lack of an appropriate textbook policy framework, which accounts for the choice of outsourcing the design and printing of textbooks Lack of schools and shortage of classrooms in good condition60 especially outside urban areas, mirror to an international publishing company. Outsourcing prevents economies of scale and leads to the acquisition inadequacy of capital spending. Current government capital spending is not enough to provide adequate learning of textbooks at exorbitant prices due to high copyrights costs. In addition, some procurement bottlenecks such and teaching environment to students and reduce SCR to reasonable levels. About a third of classrooms in public as targeted request for proposal could explain the selection of one specific, expensive, international publishing primary schools are not in ‘good condition’ (see section 4.2.3) and there is only one classroom in good condition company – a practice often symptomatic of corruption. for every 147 students in public primary schools (see Figure 4.9.) and for every 158 students in public secondary 59  Total expenditure by level of education in relation to the number of students enrolled in public and private schools in 2019. 66 60  As registered in the EMIS. 61  Central African Republic: ESP 2020-2029. 67 4.3.4. Efficiency of spending increase spending on preschool education, in line with the UNICEF-recommended target of 10 percent of the education budget. The analysis on efficiency of spending on education sector efficiency is based on an assessment of (i) allocative efficiency, (ii) technical efficiency issues, (iii) internal efficiency issues, and (iv) external efficiency issues. Despite the high needs for skills development among the youth population, CAR spent less than one percent (0.6 percent) of the education budget on TVET over 2018–20 on average, and spending on literacy and non-formal are nonexistent (see table 4.5). This puts CAR well below the SSA average (5.1 percent) and the low-income group ALLOCATIVE EFFICIENCY OF SPENDING average (5 percent) (Rawkins 2019). Allocating such a small share of the education budget to TVET is inefficient given the high unmet demand for skills training as measured by the high proportion of out-of-school youth and Functional allocation extremely low levels of literacy among the youth. Moreover, investment in TVET, especially in FCV contexts, can help reduce the chance of further conflict by ensuring youth have real employable skills and are able to find work Intra-sectoral government spending in the education sector is highly skewed toward higher education at the with those skills (Pompa 2014). There are no official recommendations on the appropriate share of education expense of preschool, secondary education including TVET, literacy, and non-formal education. As shown in spending to allocate to TVET and literacy. However, as highlighted in the Skills Training and Youth Employability table 4.5, the share of the education budget allocated to higher education and research, represented 37.3 percent ASA (Phase II), it appears necessary that CAR gradually increase spending, just like Rwanda (with 14 percent). This on average during the period 2018–20. This share is very high in comparison to the average for SSA countries (23.1 spending will help to absorb the high inactive youth population, who missed opportunities due to the prolonged percent) and LIC (23.7 percent; see figure A1.4). On the contrary, the share of the education budget allocated to period of conflicts and poor quality of education, and will contribute to peacebuilding. general secondary education (14.4 percent), TVET (0.6 percent), and preschool education (0.2 percent) is very low. Primary education takes almost half of the actual education spending, standing at 47.6 percent on average during the same period. This share is in line with the GPE recommendation of at least 45 percent of the education budget62 Economic allocation for spending on primary education in countries that, like CAR, have not yet achieved universal primary education. Government spending on education has been heavily geared toward current expenditure, with extremely limited Note that an algorithm was used to separate spending by subsector, which is discussed further in Appendix A1.2. space made for capital expenditures. Between 2018 and 2020, only 4.3 percent of government expenditure on education was allocated to capital spending. This low level of capital spending reflects the excessive reliance of the government on TFPs to finance investments in the education sector. Over the same period, the majority of CAR’s TABLE 4.5. ACTUAL GOVERNMENT SPENDING ON EDUCATION BY SUBSECTOR, 2018–20 spending on education was allocated to wages and salaries, followed by spending on goods and services. Figure 4.10 below shows the economic composition of public spending on education for two broad levels of education, HER   — 2018 — — 2019 — — 2020 — and non-HER (from preschool to secondary including TVET). Overall, spending on personnel accounted on average   Million CFAF % total spending Million CFAF % total spending Million CFAF % total spending for 62.6 percent of government education spending in 2018–20 whereas spending on goods and services averaged 20.9 percent during the same period. Furthermore, the share of spending dedicated to salary expenditures varies Preschool 33 0.2% 36 0.2% 39 0.2% by level of education: 67.1 percent on average at the non-HER level of education versus 54.9 percent on average for HER during 2018–20. Lastly, the share of non-salary spending in current expenditure is often regarded as a proxy Primary 9,353 45.2% 10,679 47.9% 12,497 49.7% of spending for the quality of education because it is generally associated with expenditures for textbooks and other learning materials. In CAR, the level of non-salary current expenditure stood at 35.4 percent on average, but Secondary 2,861 13.8% 3,225 14.5% 3,731 14.8% (excluding TVET) it consisted mainly of expenditures for (i) non-means-tested scholarships and food subsidies at the tertiary, which raises efficiency and equity concerns; and (ii) office supplies and building maintenance, with limited expenditures Secondary (TVET) 98 0.5% 122 0.5% 193 0.8% for learning materials (see section 4.3.3). HER 8,347 40.3% 8,256 37.0% 8,709 34.6% Total 20,693 100% 22,319 41% 25,169 100% FIGURE 4.10: GOVERNMENT SPENDING ON EDUCATION BY ECONOMIC CLASSIFICATION, AVERAGE 2018–20 Source: Calculations based on data from the Ministry of Finance and Budget (Ges’Co 2018-2020) Note: Preschool expenditures include those funded through the MPFFPE Government spending on preschool education is almost nonexistent even though this subsector has the Non HER subsectors potential to provide the highest return on investment of all subsectors (UNICEF 2019). Investment in preschool education is especially cost-effective as it increases primary school intake, strengthens efficiency (reduction of repetition), and improves learning and equity (Jaramillo and Mingat 2008). However, during the period 2018– 20, the proportion of the education budget63 allocated to this subsector stood at only 0.2 percent on average HER (see table 4.5), reflecting the limited public provision of preschool education. In 2019, GER at the preschool level was only 9 percent, and in 2018–19, according to data from the EMIS, only one third of the 322 preschools64 in 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% the country were publicly owned and accounted for one third of the total preschool student enrollment. The government is committed with the ESP to expanding access to quality pre-primary education and progressively Wages and salaries (*) Goods and services (**) Transfers and subsidies Capital Source: Calculations based on data from the MFB (Ges’Co 2020). Note: HER budget includes ENI’s spending. 62  See https://www.globalpartnership.org/content/gpe-funding-model-requirements-matrix. (*) include temporary and contractual teachers; (**) exclude temporary and contractual teachers 63  Includes sending by the MPFPPE. 68 64  Only six located in Bangui are managed by the MPSE, while the others were managed by the MPFFPE. 69 TECHNICAL EFFICIENCY OF SPENDING INTERNAL EFFICIENCY OF SPENDING Student-teacher ratios (STR) in CAR at the primary level are the highest in the world. CAR’s STRs (considering all Repetition and dropout rates are quite high both at the primary and secondary levels, which points to internal teachers, including community ones) are very high with 91 and 101 in 2018–19 for all primary schools and public inefficiencies, leading to low completion rates. The combination of high repetition and low completion rates point ones, respectively. Figure 4.11 presents the STR in primary schools for selected countries in SSA: it is 37 on average to a substantial waste of financial resources, including dedicating classrooms and teachers each year to repeaters. for SSA, 43 in Burundi, 28 in Ghana, and it does not exceed the threshold of 60 in any country for which WDI data Aside from financial reasons, a lower repetition rate would have the main effect of reducing dropout rates, STR, is available. The STR in CAR is more than twice the GPE-recommended level (40:1) to ensure adequate learning and SCR. Consequently, this will contribute to improving teaching and learning conditions, and therefore increase and teaching conditions. The STR in CAR is much higher in public primary schools (101 in 2018–19) compared with the quality of education. Moreover, CAR’s education system has not been effective at providing students with the private schools (60).65 necessary basic competencies as shown by extremely low learning outcomes. CAR is characterized by a high proportion of over-age students. One quarter of grade 1 students were over-age of FIGURE 4.11. STR AT THE PRIMARY EDUCATION LEVEL, CAR 2019 AND PEERS at least two years, that is, eight years old or older. The proportion of over-age in grade 1 signals that students do (AVERAGE 2016–19) not necessarily start primary school on time whereas starting on time several benefits such as increased likelihood of completing the education cycle and achieving higher lifetime earnings. Early investment in education is one of the three core tenets of education investment because it allows the foundational skills to be acquired early in 90 80 91 childhood, which make a lifetime of learning possible (World Bank 2011). Moreover, given high repetition rates at 70 all education levels and interruptions to schooling due to political and security events, the proportion of over-age 60 50 children continues to grow and by 2019 about half of lower secondary students (grades 7–10) were at least four 40 30 years behind the theoretical age for the grade they were attending. 20 10 - EXTERNAL EFFICIENCY OF SPENDING Liberia Namibia Ghana Lesotho Senegal Niger SSA average Mali Burkina Faso Benin Cote d'Ivoire Zambia Uganda Cameroon LIC average Burundi Mozambique Chad Rwanda Central African Republic CAR is caught in a “low-skill, bad-job trap” (Snower 1994) whereby very low skills are reflected by the extremely low literacy rate of those who reached grade 6 but have not been beyond primary education (24 percent and STR GPE recommended level 16 percent of men and women age 25–49, respectively). The country suffers from two interrelated issues: (i) limited availability of skilled labor and (ii) a labor market with limited job opportunities for graduates. Under Source: WDI consulted on May 2021. such a situation, external efficiency analysis is of limited interest. However, note that the performance of the CAR’s education system is still below what could be expected given the low level of public spending, as evidenced by the extremely low literacy rates of Central Africans who have attended primary school.66 As shown in table High and unequal STRs at the primary level reflect a shortage of teachers and weak capacity to deploy 4.6 below, only 12 percent of women and 22 percent of men ages 15–49 who have attended the last grade of government-paid teachers. The high share of public spending on education that goes to wages and salaries only primary school (but have not been beyond primary education) are literate. These proportions do not vary much by allows a 271:1 ratio of students to government-paid teacher of at the primary education level. As shown in figure area of residence, indicating that completion of primary school does not ensure that individuals acquire literacy 4.12, there are huge variations across SI, which reflect the limited capacity of the government to provide and anywhere in CAR. In addition, the quality of primary education does not seem to have improved recently since the deploy government-paid teachers in public schools outside Bangui. The number of students per government- literacy rates of the younger cohort (ages 15–24) who reached grade 6 are still lower than those of the older cohort paid teacher ranges from 109 in Bangui SI to 539 in the Northern SI. These differences are mainly explained by (see table A1.7 in Appendix A1.2). differences in the proportion of community teachers: it is low in Bangui (5 percent in 2018–19) and much higher in the rest of the country (70 percent). TABLE 4.6. LITERACY RATE AMONG POPULATION AGES 15–49 WHO REACHED GRADE 6 BUT HAVE NOT BEEN BEYOND PRIMARY EDUCATION FIGURE 4.12. STR AT THE PRIMARY LEVEL WITH ONLY GOVERNMENT-PAID TEACHERS, 2018–19   Women Men Ratio W/M Northen SI 539 Grade 6 12.4% 22.0% 0.56 East central SI 403 South East SI 334 BMA 11.7% 25.3% 0.46 Western SI 282 Rest of CAR 12.7% 21.5% 0.59 Central African Republic 271 Central SI 268 Urban areas 16.4% 25.0% 0.66 South central SI 245 Rural areas 11.2% 20.6% 0.54 North east SI 221 Bangui SI 109 15-24 years-old 9.0% 18.8% 0.48 0 100 200 300 400 500 600 25-49 years-old 15.6% 24.1% 0.65 Source: Authors’ calculations based on EMIS 2018–19. Source: MICS 2019, authors’ calculations 65  It is lower in Bangui than in the rest of CAR (80 versus 93), mainly because the share of the private sector is higher in Bangui than in the rest Literacy rates reflect both the access to education and the outcomes of the education system. Individuals who never attended school are 66  70 of the country. most often illiterate, and the number of years of schooling needed to be literate is a proxy of the quality of education. 71 4.3.5. Equity of spending scholarships awarded to tertiary students are not based on household wealth, given difficulties by the MES to enforce this criterion. Moreover, 61.7 percent of these scholarships are used to finance studies outside CAR. See The equity of public spending and the role of the government is assessed based on: (i) the affordability of Appendix A1.4 for more details on higher education spending. education, (ii) inequity in the provision of formal education, (iii) lack of provision of second chance opportunities for out-of-school children and youth, and (iv) inequality in access to education in terms of gender gaps. Lack of provision of second-chance opportunities for out-of-school children and youth, including displaced children and youth Affordability of education Although many school-age children and youth are out-of-school and/or displaced, there are limited second Schooling in CAR is not free and the cost of education is often an insurmountable barrier for poor families. chance opportunities programs. There are approximately over half a million children and youth ages 6–18 who At the primary and secondary levels, students and their families are charged school fees to help offset school are out of the school system. Among them, there is a large number of displaced children who had their schooling operating costs and salaries of community teachers. These fees include insurance costs, administrative costs disrupted and often interrupted. Yet, government spending on skills training for out-of-school youth (literacy (report and ID cards), exams fees, and community teachers’ salaries. Estimates based on information provided programs, accelerated learning programs,70 non-formal education, job training) is nonexistent (see section 4.3.4). by the MPSE indicate that these fees range between US$3 and US$10 per student per year, depending on the Non-formal vocational education and training is extremely limited, with centers that are hardly functioning, in grade attended. Moreover, there are also indirect costs (uniforms, transportation, textbooks, accommodation) extremely bad condition, and with at best obsolete and inadequate training equipment and tools.71 Agricultural and opportunity costs that constitute a burden for many families. However, there is not yet government spending training is almost nonexistent in CAR, although the majority of the workforce is employed in this sector and the on family aid programs or scholarships to enable poor families to send their children to primary and secondary majority of youth will still be there in the short and medium term.72 schools. Scholarships and tuition fees payment for girls will be piloted under the Human Capital and Women and Girl’s Empowerment project (P171158) to help address these challenges. Gender gaps Inequity in the provision of formal education Girls lag behind boys in both school enrollment and educational outcomes. Estimations based on MICS 2019 indicate that CAR had approximately 8.1 girls for every 10 boys enrolled in primary education, and around 6.4 girls Huge disparities in STR and SCR across school inspectorates point to inequity in the provision of primary for every 10 boys enrolled in lower secondary education. In addition, dropout rates are highest among adolescent education (see section 4.3.4). Children living outside Bangui, especially in rural areas, are disadvantaged both girls—reaching 15 and 18 percent at the lower and upper secondary levels respectively, when compared to 10 in terms of provision of government-paid teachers and adequate classrooms. The number of students per and 11 percent for boys. Consequently: (i) girls are more likely to be out of school than boys (see figure 4.3); (ii) government-paid teacher is extremely high in the Northern SI (539), East central SI (403), and South east SI (334) completion rates are extremely low, particularly for girls (figure 4.4); and (iii) literacy rates are even lower for as opposed to Bangui SI (109). The number of students per classroom in good condition is also higher in the young women—approximately 30 percent of young women ages 15–24 were able to read a simple and complete Northern SI (203), and Central SI (150) than in Bangui SI (119) and South eastern SI (113). sentence compared to 48 percent of young men in the same age group (see table A1.1, Appendix A1). To address equity concerns raised by the girls’ relatively low participation rates and education outcomes, the government has The provision of TVET and general secondary education is very limited and unevenly distributed across the elaborated a comprehensive strategy for girls’ education as part of the ESP, which will contribute to improving country. This uneven provision raises serious equity issues as many youths have few opportunities to acquire the their educational outcomes and hence their empowerment.73 skills that match their needs and desires. Due to the low population density of the country, the sparse road and transport network, and the very limited provision of secondary education (which is mainly concentrated in big urban areas), rural families often incur high accommodation costs in order for their children to attend secondary school in the nearest city or even in Bangui. As there are no scholarship programs in place for secondary students, 4.4. HUMAN RESOURCE MANAGEMENT this has created strong inequality among the youth according to whether or not they have families who can host The major bottleneck to accessing quality education in CAR is the huge deficit of qualified teachers, which is the them in these cities and parents who can finance their accommodation.67 Among the sixteen prefectures of CAR, result of weak and inadequate teacher management. The key challenges include: (i) limited capacity of existing seven do not have any public or private upper-secondary schools that offer training courses in sciences (including teacher training institutes to meet the demand for training; (ii) erratic provision of pre-service training, especially the three prefectures in the Fertit region in the Northern part of the country68) and six do not have any secondary in the 10 regional teacher training centers; (iii) irregular and lack of sustainable recruitment practices; (iv) lack of schools that offer training courses in economics (of which five also do not have any training course in sciences). incentives and control mechanisms to deploy teachers and administrative staff outside Bangui metropolitan area When they do have access to a secondary school, many Central African students do not have any other choice than (BMA); and (v) difficulties in ensuring teachers’ access to salaries. To address these challenges, the government specializing in literature. Finally, formal TVET is offered only in seven schools, with five of them located in Bangui has elaborated a set of comprehensive and integrated reforms (as part of the ESP) for improving education service with only 6,061 students enrolled, representing respectively 2.2 percent of total enrollment in lower secondary delivery across the country (see box 4.1). education and 8.2 percent of those in upper secondary education.69 This section provides: (i) a succinct description of categories of teachers in CAR; (ii) an assessment of teachers’ Public spending on HER is highly inequitable benefitting only a small share of students, mostly from wealthy training system; (iii) challenges in terms of teacher recruitment and deployment; and (iv) an analysis of the public families. As shown in table A1.6 (Appendix A1.6), spending on HER reflects (i) wages and salaries for slightly more wage bill, specifically with regards to teachers’ costs. than half; and (ii) social expenditures for over a third (mostly scholarships)—that is, 13.5 percent of the total actual education budget (Primature Comite d’Organisation du Forum National sur l’Education, 2008). The country’s high spending on tertiary education benefits only a minority of individuals as the gross tertiary enrollment rate was estimated at 3.5 percent based on EMIS 2018–19. This is a trend that ultimately favors the children of wealthier families and families living in Bangui where secondary and higher education are highly concentrated. The large 70  The government is committed to expanding the provision of accelerated learning programs (ALPs) for those whose schooling has been disrupted and often interrupted. ALPs are being piloted under the Word Bank-financed Emergency Basic Education Support Project targeting areas with high number of IDPs. These programs are expected to be scaled under the upcoming GPE-financed Education Sector Plan Support Project. 71  Training centers also have a significant lack of teaching materials and tools for practical training. The technical high school of Bangui has 67  Note that CAR does not have boarding schools except for few vocational training centers that are under the mandate of the Presidency. machines which date from 1969. The girl vocational school raises funds from students to buy raw materials for practical lessons. 68  Bamingui-Bangoran, Vakaga, and Haute-Kotto. 72  The education system does not offer opportunities for all these youth to acquire the skills that would enable them to have more productive 69  As per UIS. These proportions place CAR roughly at the same level as the average for SSA countries for lower secondary education (1.8 percent) and remunerative agricultural activities. 72 and a little below for upper secondary (13.5 percent). 73  The approach is outlined under Axis 1.2 of the ESP. See figure A1.1, Appendix A1.1. 73 Box 4.1. ESP’s strategic priorities to improve teacher management Permanent teachers are the minority at all levels of education except the tertiary level. They account for only around a third of the teacher workforce at both primary and secondary levels and 17 percent at the preschool Addressing the challenge of the teacher workforce is one of the main priorities in the ESP 2020– level. At the primary and preschool levels, they are supplemented by graduates from teacher training institutes 2029. Under Axis 2 of the ESP, “Train, recruit massively, and deploy teachers throughout the country,” the government has elaborated a set of comprehensive and integrated reforms for improving education who are awaiting integration into civil service and are hired on a renewable annual contract basis (see section service delivery across the country. These reforms can be grouped into two main categories: 4.4.3), and, most importantly, by community teachers, often untrained and without any qualification, hired and paid by parents and NGOs. In 2018–19, contractual and community teachers represented 7 percent and 63 percent 1. Recruit a large number of teachers to address the huge shortage of government-paid teachers, which of the teacher workforce in public primary schools, respectively (see table 4.7). At the secondary and tertiary level, would require: temporary teachers represented around two thirds and one third of the teacher workforce in general secondary and TVET schools and at the University of Bangui, respectively. Lastly, less than one in five primary teachers (19 • Implement a plan to recruit all graduate student-teachers as contractual teacher and/or civil percent) was a woman in 2018–19 and the proportion is even lower at the secondary (11 percent) and tertiary (8.4 servant teacher. This will allow the quick recruitment of the existing stock of graduate student- percent). Appendix A1.3 presents details for each category of teachers. teachers that are yet to be onboarded into the civil-service teacher workforce and the reinstatement of the virtuous practice of systematically recruiting all new graduate teachers into the civil service. • Increase and deconcentrate teacher training capacities to provide pre-service training and in- service training, including training of community teachers. 4.4.2. Teacher training system • Create new additional civil-servant teacher ranks that will allow recruitment of teachers with lower The teacher training system consists of two national teacher training colleges to deliver pre-service training qualifications such as community teachers. for primary and secondary teachers, respectively, and 10 regional teacher training centers to provide in-service 2. Improve teacher management to ensure equitable service delivery, which would require: training and pre-service training for instituteur adjoint or maître d’enseignement. The training college (Ecole Normale des Instituteurs—ENI) located in Bambari has the capacity to train 150 instituteurs per year. The 10 • Set up effective deployment and incentives mechanisms to encourage teachers to begin working training centers (Centres Pédagogiques Régionaux—CPR) located across the country can train a total of 500 or return to their duty station in remote areas. maitres d’enseignements per year. The training college for secondary teachers and education managers (Ecole • Modernize teachers’ payment methods to address difficulties in sending salaries close to the civil- Normale Supérieure—ENS) is located in Bangui; it has the capacity to train 240 secondary teachers (both general service teachers’ duty stations. and technical education) per year. Furthermore, the MPSE does not yet have a pre-service training program for • Remunerate community teachers as a short-term solution in order to lessen the burden on poorer preschool teachers; but the MPFFPE has been training on average 80 preschool instructors (moniteurs) per year communities. since October 2018. • Set up a human resource management information system (HRMIS) to ensure successful implementation of the reforms related to teachers. Existing ENI, ENS, and CPRs are insufficient to meet the demand for training, and enrollment into these institutes has not only been irregular but also very centralized: 1. The current total teacher training capacity falls far short of CAR’s needs for the next decade: to reach an STR of 50 by 2030 in public primary schools, it will be necessary to quadruple the current number of teachers (to 4.4.1. Categories of teachers in the education system about 16,082; see section 4.5.1), which will include trained community teachers. There are two types of teachers in CAR: government-paid teachers and community or NGO-paid teachers. 2. There is no fixed budget line to ensure regular pre-service training for maîtres d’enseignement. The Government-paid teachers consist of permanent teachers, contractual teachers at the primary level, and enrollment of student-teachers in CPRs has been erratic since 2009 because the government never covered temporary teachers at the secondary and tertiary levels. Community or NGO-paid teachers are teachers hired the costs of pre-service training. These trainings are therefore completely dependent on TFPs, which do not by parents to make up for the lack of government-paid and trained teachers in primary schools and preschools have a long-term financing plan. As a result, there was no enrollment of student-teachers in CPRs in 2011, 2012, (see Appendix A1.3 for further details). Overall, the Central African education system relies to a large extent on 2014, 2020, and 2021.74 (i) community teachers at the preschool and primary levels, constituting a heavy burden on poor families; and (ii) temporary teachers at the secondary and tertiary levels. Table 4.7 presents the main categories of teachers in 3. Admission into ENI and ENS tends to be very centralized. Until 2019, the entry exam to enroll into ENI was public schools by level of education in CAR. managed by the Central level75 and many student-teachers enrolled in the CPRs and ENS come from BMA. Recruiting a large number of teachers will require an increase in the capacity of ENI, ENS, and CPRs to provide pre-service and in-service teacher education, especially outside Bangui. To address these challenges the TABLE 4.7. CATEGORIES OF TEACHERS IN PUBLIC SCHOOLS BY LEVEL OF EDUCATION, 2018–19 government policy as laid out in the ESP involves:   - Preschool - - Primary - - Secondary G. - - Second. TVET - - Tertiary - 1. Increasing the number of ENI, ENS, and CPRs to train a total of 3,920 teachers (pre-service and/or in-service) per year by 2030 (in comparison to 1,070 as of 2019).   N % N % N % N % N % Permanent 48 17% 2,972 30% 718 34% 104 36% 289 69% 2. Decentralizing teacher training for primary and lower secondary school teachers, and creating training programs for preschool teachers. This decentralization will allow to train existing community teachers in Contractual/ proximity to their duty stations so that they can be converted progressively into agent d’éducation who are 13 5% 681 7% 1,401 66% 182 64% 127 31% temporary Community 220 78% 6,175 63% n.a n.a n.a n.a n.a n.a 74  The GPE-financed project ESPSP was suspended due to the security situation and could not finance training of teachers in 2011, 2012, and Total 281 100% 9,828 100% 2,119 100% 286 100% 416 100% 2014. In 2017, training was not provided due to delays in the EU funding. Finally in 2020 and 2021, training was not provided due to lack of financing from TFPs as most projects (in particular those financed by the EU and GPE) have closed. Source: EMIS 2018-2019, authors’ calculations 75  The World Bank-financed Second Consolidation and Social Inclusion Development Program (P168474) 2018–2019 supported reforms on 74 decentralization of primary teacher recruitment and deployment through the introduction of the five-year commitment policy. 75 recruited and paid by the government either as contract teachers or civil servants.76 The decentralization of Box 4.2. An update of the ESP’s recruitment strategy for all graduate student- training is also expected to improve teacher deployment (see section 4.4.3). teachers 3. Transforming the mandate of ENIs whereby they will not only train primary teachers but also preschool and One of the key and pressing strategies put forth in the ESP is implementation of a plan to recruit all lower secondary teachers. This will allow the MPSE to offer pre-service training program for preschool teachers, graduate student-teachers as contractual and/or civil servant teachers. In the initial plan, the government which is currently nonexistent, as well as recruit and train lower secondary teachers outside of Bangui and would have reverted in 2024 to the virtuous practice of systematically recruiting as contractual teachers and/or civil servant teachers all student-teachers. This plan was derailed in light of recent events (teachers improve their deployment later on. strikes and the heat of presidential elections). Therefore, a revised five-year plan is proposed under this 4. Transforming the mandate of CPRs whereby the CPRs will not only train maîtres d’enseignement but also PER and is expected to begin in 2023. This plan accounts for the latest wave of recruitment that happened between December 2020 and February 2021. community teachers (agents d’éducation) and temporary lower secondary teachers. Overall, the government should recruit a number of teachers each year for five years (2023–27) that corresponds to the total number of new graduates plus one fifth of the stock of graduates from previous 4.4.3. Teacher recruitment and deployment years still waiting to be integrated in 2022. Recruitment of these graduate student-teachers will be done by order of seniority, beginning with those who graduated in 2009. When this stock is exhausted in 2028, TEACHER RECRUITMENT recruitment will exclusively concern new graduates. See Appendix A1.3 for further details. There have been no regular and sustainable teacher recruitment practices in place since 2009, and The implementation of this plan will require: approximately 4,032 graduate student-teachers were awaiting integration into civil service as of May 2021. • Restoring and securing all budget lines dedicated for paying contractual and temporary teachers (see Graduate student-teachers are no longer integrated systematically into civil service. Following the 2016 4.3.4). presidential election, the government put in place a recruitment plan in which 1,500 people will be recruited • Identifying and making a registry of all graduate student-teachers awaiting integration into civil yearly, with a quota of 300–400 recruits for the education sector (both teachers and other education personnel). service who are still interested in working as teachers and who will likely be recruited as contractual This quota is lower than the number of teachers who graduate each year from ENI, ENS, and CPRs; but, in and/or civil servants. addition, recruitment between 2016 and 2020 was effectively carried out only twice for the education sector. • Offering a contract to all these graduate student-teachers (those awaiting integration into civil Instead of being systematically recruited into civil service, until December 2020, (i) some graduates from ENI and service) and new graduate student-teachers starting in September 2023 (beginning of the school CPRs were hired as contractual teachers77 and (ii) some graduates from ENS were hired as temporary teachers. year). Despite a large number of newly recruited teachers (1,360 primary and secondary teachers78) preceding the Lastly, the IDA-financed CAR First Resilient and Inclusive Institutions for State Effectiveness DPF 2021– December 2020 presidential elections, there are still 1,256 instituteurs, 2,133 maitres d’enseignement, and 643 2022 (P175173) will help lay the foundations for successful implementation of the ESP’s recruitment secondary teachers (see table A1.8 in Appendix A1.3) who have graduated from a training institute but have not strategy for all graduate student-teachers (see Appendix A1.2). yet been integrated. To address this rather unfair and inefficient situation, the government is committed to implementing as a first step a plan to recruit as contractual teachers and/or civil servant teachers, all graduate student-teachers awaiting integration (see box 4.2 for more details). The following should be noted: TEACHER DEPLOYMENT 1. This recruitment plan is a prerequisite to rebuild the education system. First, politically and according to the The proportion of community and temporary teachers is a lot higher outside Bangui metropolitan area, both in rules of the CAR administration, it is not possible to recruit new teachers independent of their rank until those primary and secondary schools. Based on the payroll data, there are many prefectures without a single permanent already trained have been recruited. Second, it is legitimate, and socially and morally right, to proceed in this teacher, mostly in the North-eastern and Eastern parts of the country (for example, there is no permanent teacher manner, as it fulfills the state’s commitment to these student-teachers from before they entered training in public primary schools of Vakaga prefecture). The situation is even worse at the secondary level, as there is institutes.79 Lastly, it would be inefficient not to recruit already trained teachers given the high shortage of no single permanent teacher in 4 out of the 16 prefectures (Vakaga, Haut-Mbomou, Haute-Kotto, and Sangha- teachers. Mbaere). In addition, there are less than 10 permanent teachers at the primary and the secondary level in three and four prefectures, respectively.80 Furthermore, government-paid teachers are sometimes not at their duty station, 2. This recruitment plan represents only a small part of the overall strategy designed to address the shortage which is perceptible to some extent through the differences between teachers recorded in the EMIS (supposed to of qualified teachers. More significant, for example, is the massive training of community teachers and their be at their duty station) and teachers recorded on the payroll and budget (see table A1.9 in Appendix A1.3). Making recruitment as agent d’éducation, which provides them with a more stable teaching rank (see box 4.1). matters worse, the recent integration of teachers was carried out without putting in place a mechanism to deploy teachers, especially in hard-to-reach areas. In addition, budget lines used to hire contractual and temporary teachers have been cancelled, which will worsen the current situation as many secondary schools outside Bangui will be without teachers. As shown in figure 4.13 below, in 2018–19 the proportion of community teachers was as high as 92 percent in the Haut-Mbomou prefecture, compared to only 8 percent in Bangui. In secondary schools, the proportion of temporary teachers was 100 percent in both Vakaga and Haute Kotto, compared to only 31 percent in Bangui. 76  Both options are considered in the ESP. 77  This is a tri-party contract as it involves three ministries, namely Education, Finance, and Civil Service. However, communities are not part of this process despite efforts made to involve them. The same contract was offered to both ENI and CPRs graduates. 78  The number of new recruits was expected to reach 1,700 teachers by the end of 2021. 79  Overall, CAR is a country where the political and security condition is extremely fragile and volatile. Care must be taken to maintain the existing fragile balance. Therefore, there must be consideration of the political demands of various groups such as graduate student-teachers 80  These prefectures are Haut-Mbomou, Haute-Kotto, and Basse-Kotto for the primary level and Kemo, Nana-Mambere, Ombella Mpoko, and 76 awaiting integration, as their claims are legitimate from the point of view of CAR administrative law. Ouham-Pende for at the secondary level. 77 FIGURE 4.13. PROPORTION OF COMMUNITY TEACHERS (LEFT) AND TEMPORARY TEACHERS most student-teachers come from Bangui (especially at ENS, including the regional CPRs) and are reluctant to (RIGHT) BY PREFECTURE, 2018–19 accept a position elsewhere. Challenges mentioned under (i) and (iv) have been discussed above and those under (ii) and (iii) are presented below. The government’s ability to deploy teachers outside of BMA is weak due to the absence of incentives and monitoring mechanisms. There are no special allowances granted to teachers who work in remote areas. Tertiary teachers benefit from a housing allowance while they all live in Bangui, but primary and secondary teachers who work outside Bangui do not benefit from this allowance. Also, as shown in figure 4.14, there are no significant differences in teachers’ salaries between those working in Bangui and outside Bangui. Teachers of the same rank earn more or less similar salaries wherever the location of their duty station. For example, a maître d’enseignement working in Bangui earns on average CFAF 97,633 per month, which is close to what maître d’enseignement working outside Bangui (CFAF 95,419) will also earn. FIGURE 4.14. TEACHER AVERAGE GROSS MONTHLY SALARY (CFAF) BY REGION AND TEACHING RANK IN 2020 180,000 168,646 156,978 150,000 135,548 123,567 126,424 117,257 120,000 97,633 95,419 90,000 60,000 30,000 - Bangui Out. Bangui Bangui Out. Bangui Bangui Out. Bangui Bangui Out. Bangui (20) (15) (17) (15) (8) (9) (11) (10) INSTITUTEUR ADJOINT INSTITUTEUR PROFESSEUR DE COLLÈGE PROFESSEUR DE LYCÉE Base salary Allowance Source: Authors’ calculations based on the Ministry of Finance and Budget data Many teachers must travel long distances to collect their salaries in one of the provincial capitals with a bank, which contributes to high teacher absenteeism. The collapse of the postal and banking networks outside of Bangui since the 2000s makes it difficult to pay teachers’ salaries.81 This is one of the reasons why it is difficult to maintain teachers in their respective postings. There is no data on teacher absenteeism of teachers; however, evidence collected during school visits conducted during the elaboration of the ESP between 2019 and 2020 show that teachers are often absent for several days (even weeks) to go collect their salaries. Teacher absenteeism can be seen to some extent through the differences between teachers recorded in the EMIS (supposed to be at their duty station) and teachers recorded on the payroll and budget (see table A1.9 in Appendix A.1.3). Since 2019, the MFB has been actively piloting the Patapaye mobile payment system to enable paying civil servants’ salaries through mobile money. A current limitation of this payment system is that it excludes contractual and temporary teachers paid by the MFB. Community teachers do not have logistical difficulties in receiving their salaries, but their pay is very low and highly irregular. Absenting themselves is often the only way to put pressure on poor families until they receive compensation. The shortage of government-paid teachers must be addressed together with improvement in teacher Source: EMIS 2018-2019, authors’ calculations management policy. As highlighted in the ESP, improvement in management policy can be achieved through: 1. Setting up effective deployment mechanisms and incentives, which are critical to ensure equitable service Several factors contribute to the relatively large proportion of unqualified primary and secondary teachers delivery. This policy requires developing a deployment plan including strategies to encourage teachers to outside Bangui. These factors are among others: (i) the volatility of the security situation and unfavorable begin working or return to their duty station in remote areas, such as: conditions related to housing outside Bangui; (ii) the lack of incentives for teachers to be deployed outside Bangui and the weakness of control mechanisms to monitor deployment; (iii) the difficulties in accessing salary payment 78 outside urban cities; and (iv) the centralized recruitment of student-teachers in ENI until 2019 and the fact that 81  Source: CAR Education Sector Strategy (2008), CAR Education Interim Plan (2014–2017). 79 a. Extending the five-year commitment policy recruitment to all teachers (pre-primary to secondary levels). Accounting for 24.1 percent of total public sector employment and 20 percent of the public wage bill over the This commitment policy states that after their training, graduate student-teachers will teach for at least period 2017–20, the education sector is the second largest sector of employment in public administration, after five years within the SI where they took the entrance exam to teacher training college or center. This defense and public order sector. The overall public sector wage bill in CAR as a percentage of GDP remained stable policy constitutes a measure to ensure availability of teachers in all SI. from 2017 (4.8 percent) to 2020 (5 percent), but the education wage bill as a percentage of this bill has decreased from 26.2 percent in 2017 to 18.2 percent in 2020.84 This large relative decrease is driven mostly by both (i) the b. Decentralizing the organization of the entrance exam to CPRs and ENIs, which will allow to train teachers limited number of recruits in comparison to departures in the education sector85 until December 2020; and (ii) in proximity to schools where they will be posted once recruited. the high number of recruits in the defense and public order sector.86 As a result, the number of employees for the education sector on the payroll decreased from 6,908 in 2017 to 6,506 in 2020 (that is, by 6 percent), whereas the c. Incentivizing permanent teachers to spend several years in remote areas by offering bonuses and number of employees in the defense of public order sector increased from 11,364 to 15,670 during the same period attractive career plans, such as granting them opportunities to upgrade their teaching rank. Note that (that is, by 38 percent; see table 4.8). The public wage bill can be considered moderate given that it stands below financially incentivizing permanent teachers to take up positions outside Bangui is only a minor measure the SSA average (7.1 percent of GDP in 201987). Even including the costs of contractual and temporary employees of the overall strategy to address shortage of teachers in schools82 (see section 4.5.1). would put the overall wage bill at only 5.3 percent of GDP in 2020. It would be necessary to carry out a more d. Eliminating unilaterally decided transfers, which often arise as a result of favors from individuals in detailed diagnostic of the wage bill using information on the wage premium in the public sector, and the value of higher positions (for example, ministers) for particular teachers. This is another measure that will ensure the salary scale index point which remained unchanged since 2000.88 availability of teachers in all SI. e. Monitoring teachers’ presence in their duty stations by involving communities and the SI, and by providing TABLE 4.8. WAGE BILL AND SIZE OF PUBLIC SERVICE IN CAR (2017-2020), TOTAL AND appropriate sanctions to address absenteeism. EDUCATION SECTOR 2. Modernizing payment methods to address teachers’ difficulties in accessing salaries close to their duty   2017 2018 2019 2020 stations. In addition to Patapaye, other means are also being explored and may prove to be complementary, such as payment via post offices, trusted third parties (such as churches), and others.83 Total public wage bill         3. Setting up a HRMIS to ensure effective monitoring of teachers. The HRMIS (mentioned in Chapter 3) % of GDP 4.8% 4.7% 4.8% 5.0% specifically for the education sector will cover all teachers whether they are civil servants. Specifically, it will Million CFAF 57,400 58,967 63,747 68,566 (a) link teachers’ salary payment from the MFB’s payroll system to their presence in their respective duty station; (b) link teacher deployment to the school mapping system that will be put in place under the EMIS; Total public employees (#) 26,372 26,843 27,654 31,035 (c) be accessible and used by SI to allow close monitoring of teachers; and (d) provide detailed information (including pedagogical training received) on all categories of teachers. Both the Education Sector Plan Support Average monthly wage bill per employee (CFAF) 181,380 183,061 192,097 184,108 Project (P173103) and the Public Sector Digital Governance Project (P174620) are expected to support the establishment of the HRMIS. Education wage bill         % of total public wage bill 21.3% 21.1% 19.4% 18.3% 4.3.4. Wage bill management Million CFAF 12,230 12,460 12,339 12,574 The government finances salaries of permanent teachers, contractual teachers, and temporary secondary Education employees (#)         teachers via two different mechanisms: the standard payroll system and specific budget lines under “goods and services.” The payroll system is used to pay permanent teachers every month over 12 months based on the % of total public employees 26.2% 25.6% 23.7% 21.0% public service pay scale; whereas salaries spending for primary contractual teachers and secondary temporary teachers are currently considered “goods and services” spending under the budget. Awarding such contracts is Number 6,908 6,863 6,551 6,506 a way for the government to employ (contractual and temporary) teachers without significantly increasing the apparent value of the wage bill. The first wave of contractual agents started in 1985. The public Treasury ensures Average monthly wage bill per employee (CFAF) 147,531 151,299 156,961 161,060 payment every three months for a nine-month contract for contractual teachers and once a year for secondary Source: Calculations based on data from the Ministry of Finance and Budget (Payroll 2017–2020) and the World Economic Outlook (2020). temporary teachers (based on a nine-month allowance). In 2020, the costs of contractual and temporary teachers amounted to CFAF 2,611 million, accounting for 15.8 percent of the education wages and salaries spending and 70.8 percent of total government costs for all contractual and temporary employees. However, following the latest integration of teachers, the MFB cancelled the budget lines used to hire contractual teachers and temporary teachers, without a plan in place to make up for the deficit of teachers especially outside Bangui. As the system cannot function without these teachers, this is likely going to increase the proportion of community teachers. 84  The level of the education wage bill (in 2020 constant prices) increased from CFAF 12,994 million in 2017 to CFAF 12,574 in 2020, which Parents have started paying the salaries of contractual and temporary teachers in some SI. corresponds to a 3.2 percent decrease over the period. 85  Estimations based on the payroll indicate that between 2017 and 2020, the number of new recruits stood at 357 in 2018 and 310, whereas departures amounted to 380 in 2018, 331 in 2019, and 351 in 2019. 86  The number of employees increased from 11,364 in 2017 to 15,670 in 2020. 87  IMF estimates 2019. 88  “For example, if the wage bill is high because of a large share of public employees, measures on employment—such as attrition—can be effective in providing short-term relief. Alternatively, if the wage bill is high because government wages are high relative to the private sector, 82  The existing teacher cadre, especially instituteurs, will remain the minority of the teacher workforce and will constitute a very small containing compensation can be a strategy to enhance the efficiency of spending (IMF, 2016f ). Indeed, compensation measures are usually part proportion of teachers who will work in remote areas. of any wage bill reform as, on average, public sector wages are often higher than private wages for comparably skilled workers—with the wage 83  This issue will be further addressed by establishing: (i) a working group to regularly report on the options tested; and (ii) an action plan to premium being lower for AEs (at around 5½ percent) compared to EMs and LIDCs (at around 12¼ percent) (IMF, 2016a; and IMF, 2016f ).” See IMF 80 search for site-specific solutions based on a detailed mapping of the country. 2019. 81 Permanent teachers are paid at a higher rate than health sector employees with the same level of qualification. 3. Temporary teachers at the secondary education level provide 15 hours of teaching per week and receive a lump Figure 4.15 presents the average gross salary of employees for three selected sectors (defense and public order, sum payment equivalent to CFAF 270,000 per year. At best, they receive this amount from the government in education, and health) organized by level of qualification: a single payment at the end of the school year. At the University of Bangui, temporary teachers usually receive CFAF 4,500 per hour, which is paid at the end of an academic year 1. The provision of allowances is not standardized across the administration as the proportion of allowances relative to total gross salary is lower for primary and secondary teachers in comparison to other sector 4. Finally, UNICEF-supported NGOs pay community teachers a salary equivalent to CFAF 315,000 per year, but employees. In 2020, allowances constituted about 13 percent of instituteurs and professeurs de collège total communities rarely reach half that amount and often much less in rural areas89 and they are paid irregularly. pay on average, whereas it stood at 49 percent and 19 percent for an army sub-officer and a nurse respectively. 5. In comparison with other SSA countries with a comparable level of development, CAR has both a low number 2. The gross salary of a maître d’enseignement is significantly higher than other professions of an equivalent of government-paid teachers per capita and a relatively high salary level for them at the primary level. On one qualification, which is not the case for other categories of teachers. On average, a maître d’enseignement hand, CAR has a very low ratio of 1 government-paid teacher per 1,000 people in comparison to countries like earns CFAF 96,157 per month whereas an assistant nurse earns only CFAF 78,090 per month (19 percent Botswana (6 per 1,000), Burkina Faso (4 per 1,000), and Cameroon (2 per 1,000). On the other hand, the average less). However, instituteurs and professeurs de lycée are paid less than their peers in the defense and public primary teacher salary, expressed in multiples of per capita GDP, stands at 4.8 in CAR, which is above the SSA order sector. A police officer earns on average CFAF 142,638, whereas an instituteur with the same level of average (3.76), the average for low-income countries (3.85), and the GPE recommended level (3.5). The low qualification (even a little higher) earns a relatively lower amount CFAF 120,084. number of government-paid teachers relative to the population further justifies the needs to increase teacher recruitment in CAR to ensure the expansion in education coverage, reduce the financial burden on families, and improve learning conditions. FIGURE 4.15. AVERAGE GROSS SALARY (IN ‘000 CFAF) FOR SELECTED PUBLIC EMPLOYEES IN 2020 FIGURE 4.16. PRIMARY TEACHER SALARY AS MULTIPLES OF GDP PER CAPITA, CAR AND 450 SELECTED SSA COUNTRIES 412.5 400 329.6 350 325.4 300 7.0 250 200 162.7 172.8 6.0 142.6 129.8 150 120.1 121.1 119.6 124.8 77.5 80.0 96.2 100 73.9 78.1 5.0 50 4.8 0 4.0 Ass. nurse (8) Med. doctor (6) ASSISTANT-UNIV (9) INSTITUTEUR (16) Nurse (8) Ass. midwive (7) INSTITUTEUR ADJ (17) Midwife (10) PROF. LYCEE (11) Army soldier (5) PROF. COLLEGE (8) Police sub-officer (9) Army officer (21) Police sup officer (9) Police Officer (18) Army sub-officer (15) 3.5 3.0 2.0 NO BASIC EDUCATION diploma UPPER SECDRY dip. UPPER SECDRY dip. BACHELOR MASTERS 1.0 diploma + 1-2y + 1-2y + 3y + 1-2y + 4-5y Base salary Allowance - Botswana Congo, Dem Gambia Cameroon Côte d'Ivoire GPE Burkina Faso Central African Rep. recommended Republic Source: Authors’ calculations based on the Ministry of Finance and Budget data (Payroll 2020). level Note: Numbers into brackets within the occupations indicate average years of experience. Source: Compilations based on country studies and PERs. For CAR, authors’ calculations based on payroll data (2020). Permanent teachers’ salaries are significantly higher than salaries of contractual and temporary teachers, and a fortiori community teachers. As shown in table A1.10 in Appendix A1.3: The large differences between the salaries of permanent teachers and community teachers and temporary teachers justify the creation of new lower-cost teacher ranks to realize needed massive recruitments. The 1. Upon integration into civil service, permanent teachers (that is, instituteurs and instituteurs adjonts) received strategy to address the shortage of teachers is expected to create new lower-cost teacher ranks to be able to an initial gross salary of CFAF 1.1 million and CFAF 1.0 million per year, respectively. Moreover, salaries of these recruit a massive number of teachers and reduce the burden on poor families (see box 4.3 below). At the primary teachers increase as they progress up the career ladder. level, most new recruits will be community teachers who are already in public schools. Specifically, they will 2. In contrast, contractual teachers receive a fixed allowance equivalent to CFAF 540,000 per year. Not only it is be trained in close proximity to their duty station and offered a more stable status as agent d’éducation who almost half the average base salary (minimum value) of a permanent primary teacher, even though they have expected to be paid by the government. the same level of qualification, but also it is lower than the monthly gross salary of an army soldier whose position does not require a diploma. Contractual teachers should be paid in theory every three months by the public Treasury, normally upon producing a certificate of service duly signed by the school principal, the head of school subdistrict, and the SI. But they rarely receive their salary as planned and are not paid regularly given the observed arrears. 89  For example, visits and focus groups with parents and community teachers in Ndele indicated that a community teacher often can receive 82 CFAF 1,000 to 15,000 per month, for a period of 9 months. 83 Box 4.3. Five additional civil service teaching ranks to be created to absorb the new 4.5.1. Financing needs of the education sector recruits Financing needs are measured based on the following key elements: (i) evolution of student enrollment over the As part of the proposed teacher recruitment policy under the ESP, five additional civil servant teaching period 2022–30; (ii) number and composition of the teacher force needed to provide teaching and learning and ranks are expected to be created. These new teaching ranks will provide better and more stable jobs STR to be achieved in 2030; (iii) number of classrooms needed to accommodate students and SCR to be achieved to community, temporary, and preschool teachers. They will be paid at a higher rate than the current in 2030; (iv) goods and services needed to ensure quality of education, including learning and teaching materials community and temporary teachers, and will contribute to managing changes in the wage bill. and textbooks; and (v) transfers and potential demand-side interventions such as scholarships (especially for Furthermore, the existence of different teaching ranks (new and old)—and therefore different salary girls) and second chance opportunities programs for out-of-school youth. rates—for the same position will be better accepted if it is possible to progress from one teaching rank to another. Teachers starting out with a lower teaching rank should be able to gradually move up the career ladder. In addition, mobility between different positions—and functions—is necessary to better respond NUMBER OF TEACHERS NEEDED IN PUBLIC SCHOOLS BY 2030 to the changing needs of the national education system and is an incentive for teachers willing to move up the career ladder. One of the main objectives of the education strategy is to enable the education system to transition from the current situation to a desired outcome where schools are run by qualified and government-paid teachers. The These new additional teaching ranks are: agent d’éducation, professeur polyvalent du secondaire, and three ranks for the teacher workforce at the preschool level. current situation is characterized both by (i) a shortage of teachers given high STR and (ii) a high proportion of untrained teachers. As shown in table 4.9 below, to achieve this transition, it would be necessary to train and recruit At the primary level, agent d’éducation is reserved for community teachers that will receive 1–3 years in- a very large number of teachers in order to move from 12,621 teachers in 2018–19 to 30,192 teachers in 2030–31 service training at CPRs and could be hired by the government upon graduation. Their initial gross salary in public schools at all levels of education.90 A set of complementary reforms related to teacher management as is expected to be set at CFAF 40,000 per month for 12 months. This compensation is significantly than for outlined in box 4.1 will need to be implemented to ensure achievement of this objective. Overall, addressing the the two existing teaching ranks at the primary level, and lower than the starting salary of an army soldier shortage of teachers while reducing the proportion of unqualified teachers requires: (without qualification), but significantly higher than the maximum compensation that a community teacher can expect (table A1.10). 1. Increasing the number of teachers present in schools to decrease high STR and cope with the expected increase in enrollment at all levels of education; and At the secondary level, professeur polyvalent du secondaire will be reserved for temporary secondary 2. Converting the significant number of existing community teachers who are untrained with no qualification at teachers (those who intend to become permanent teachers) and existing instituteurs. They will benefit both primary and preschool levels into agent d’éducation (that is, trained teachers with a with a more stable from multidisciplinary in-service training in CPRs during school holidays, over two years, and will obtain an intermediate rank and associated salary between that of an instituteur and that of a professeur de status). collège. These teachers are primarily intended to teach in local lower secondary schools (collèges de proximité). TABLE 4.9. NUMBER OF TEACHERS IN PUBLIC SCHOOLS, 2018–19 VERSUS 2030–31 There are currently no teaching ranks at the preschool level. As the government develops this subsector, it is expected to set up three teaching ranks that will mirror the primary level ranks: insitituteur, maître   2018—2019 2030—2031 d’enseignement, and agent d’education.   Teachers (#) % permanent teachers STR Teachers (#) % permanent teachers STR Preschool 281 17% 43 5,445 88% 30 Primary 9,828 30% 101 16,082 89% 50 4.5. FINANCING NEEDS AND SUSTAINABILITY OF PUBLIC SPENDING Secondary (exc. TVET) 2119 34% 54 7,375 100% 50 ON EDUCATION Secondary (TVET) 393 42% 19 1,290 61% 35 This section presents the financing needs of the education sector based on the recently adopted ESP 2020– 2029 and assesses its fiscal implication and sustainability. Financing needs for the education sector presented Total 12,621     30,192     in this section are based on the simulation model developed for the ESP 2020–2029. However, the results of the simulation carried out as part of the ESP have been updated to reflect the strong impact of the COVID-19 Sources: ESP Simulation Model revised in 2021 and EMIS 2018–2019. Note: Number for TVET is for both public and private schools. pandemic and 2020–21 elections turmoil on the government revenues and education sector, including school closures and loss of learning opportunities and delays in implementation of planned ESP interventions (school and teacher training, institute constructions, teacher training, and so forth). To accommodate the two shocks: At the primary level, reducing the STR in public schools from 101 in 2018–19 to 50 in 2030–31, will require having (i) the realization of the ESP targets originally planned for 2029 have been postponed by one year and are now 16,082 teachers at the beginning of the 2030–31 school year (see table 4.9). In 2018–19, the total number of set to be achieved by 2030; and (ii) the values of some parameters and selected targets have also been modified teachers in public primary schools was close to 9,830, but only 3,655 were trained teachers. This number will (see Appendix A1.4). Overall, the level of financing needs depends on a set of agreed targets and scenarios have to more than quadruple to reach a modest STR of 50 in 2030. As shown in figure 4.17, this outcome can only that are deemed feasible and attainable over the next decade. Under this PER, only the results of the updated be achieved by training a large number of maitres d’enseignement (N = 6,243 in 2030) and agent d’éducation baseline scenario of the ESP projections are presented. These results constitute the median scenario. Appendix (N=4,088 in 2030) in regional CPRs.91 The baseline scenario ensures to move from a situation where 30 percent of A1.4 presents targets and assumptions made under the baseline scenario and discusses succinctly three other teachers were permanent teachers in 2018–19 to a situation where 88 percent are in 2030–31. scenarios that were developed as alternatives. 90  Note that the number of private sector teachers will also have to increase (the SM’s assumption is that the share of private education will remain constant at about 20 percent over the decade) and these teachers are often trained in public training institutes. 84 91  The number of trained instituteurs will also increase, but less rapidly. 85 FIGURE 4.17. BASELINE SCENARIO—PROJECTED CHANGES IN THE COMPOSITION OF THE TABLE 4.10. NUMBER OF CLASSROOMS BUILT OR REHABILITATED OVER THE PERIOD 2021–30 TEACHER WORKFORCE AT THE PRIMARY LEVEL (PUBLIC SECTOR ONLY) AVAILABLE IN 2030 IN PUBLIC SCHOOLS   SCR “good condition” Number of classrooms by 2030-2031 8,000 7,000 6,175 6,243   2018-2019 2030-2031 Built Rehabilitated Total 6,000 Preschool 79 45 3,537 318 3,855 5,000 4,088 Primary 148 65 3,945 3,950 7,895 4,000 3,000 3,708 Secondary (exc. TVET) 158 95 3,229 412 3,641 1,746 2,000 Secondary (TVET) 65 60 730 69 799 1,908 2,043 1,000 0 Total     11,441 4,749 16,190 0 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Sources: ESP Simulation Model revised in 2021; EMIS 2018–2019. Instituteurs Maitres d'enseignement (ME) Agents d'éducation (AE) Community teachers Sources: ESP Simulation Model; EMIS 2018–2019. 4.5.2. Implications for government spending on education The country’s economic growth has been revised downward for 2020 from 5.0 percent to 0.0 percent due to the Training the required number of secondary teachers by 2030 will be as challenging as training teachers at the COVID-19 pandemic and elections turmoil. However, the current forecast projects real GDP growth to recover to primary level, and thousands of preschool teachers will be needed to develop preschool subsector. Expanding 3.5 percent in 2021 and to average 4.7 percent in 2022–30. the provision of secondary general education while achieving a relatively high STR of 50 will require having nearly 7,375 teachers by 2030–31 in public schools while there were only 718 permanent teachers and 1,401 temporary Achieving the baseline scenario requires progressively increasing total public spending on education, as a teachers in 2018–19 (see figure A1.5 in Appendix A1.4). Moreover 5,445 public preschool teachers would be needed proportion of GDP, from the average value of 1.9 percent during 2018–20 to 3.3 percent in 2030. This proportion to achieve a 95 percent gross intake rate to the last grade of preschool with a STR of 3092 at the beginning of the will remain below the SSA’s average in 201893 (4.6 percent), but it will require increasing spending on education 2030–31 academic year, whereas there were only 61 in 2018–19 (see figure A1.6 in Appendix A1.4). as a percentage of total government spending (see section 4.5.3). This also has implications for the evolution of spending by category and by subsector as described below. The breakdown of public spending on education into As envisioned by the government, the strategy to address the teacher shortage at the primary level would current and capital expenditures and by subsector are presented in table A1.13 and table A1.14 in Appendix A1.4, be a hybrid model. As shown in figure 4.17, on one hand the system will continue to rely on the existing teacher respectively. cadre (instituteurs) but they will remain the minority of the teacher workforce representing about 18 percent of teachers hired between 2020 and 2030. On the other hand, a large proportion of community teachers (75 Capital expenditures as a proportion of total spending on education are projected to gradually increase whereas percent) will be trained, provided with adequate pedagogical skills, and recruited as agent d’education either on the share of salaries and wages expenditures would decrease. On one hand, capital expenditures would account a contractual or civil servants basis. These regularized community teachers (agent d’éducation) are expected to on average for about 26.6 percent of total public spending on education during the 2021–30 period. This high represent about 40 percent of teachers hired between 2020 and 2030 and they will be paid by the government proportion is explained by the huge construction and rehabilitation needs across all subsectors. On the other instead of poor parents. hand, the wage bill (including salaries of contractual, temporary teachers, and community teachers) will more than double (in constant prices) from CFAF 18.7 in 2021 to CFAF 42.3 billion in 2030, due to the large number of teacher recruitments. However, the share of salaries and wages expenditures in total spending on education is NUMBER OF CLASSROOMS/PUBLIC SCHOOLS NEEDED BY 2030 expected to decrease from 61.3 percent in 2021 to 59.3 percent in 2030. The total number of classrooms required to improve access and learning conditions in public schools at all The proportion of public spending on education allocated to primary education is expected to stand at 38.3 levels of education (except tertiary) at the beginning of the 2030-2031 school year stands at 16,187, whereas percent on average during the 2021–30 period,94 whereas the share allocated to preschool and secondary there were only 7,682 classrooms in good condition in 2018-2019. As shown in Table 4.10, existing classrooms are education will significantly increase. Indeed, the expanded provision of preschool education, which is currently overcrowded, with on average one classroom in good condition for every 148 students in public primary school and at a nascent stage, will require increasing the proportion of spending to this subsector from 0.2 percent in 2020 158 students in public secondary school, respectively, in 2018-2019. Based on the simulation model, it is estimated to reach 12 percent of the education budget in 2030. Moreover, the expansion of secondary education, in line that 3,942 and 3,950 classrooms will need to be constructed and rehabilitated, respectively, in order to improve with achieving SDG targets,95 will necessitate dedicating about 32.9 percent of the education budget to this access and reduce SCR from 101 in 2019 to 65 in 2030 in public primary schools. In secondary education (excluding subsector in 2030 (28.9 percent for general education and 4.0 percent for TVET). Note also that the high level TVET), it is estimated that 3,229 and 412 classrooms will need to be constructed and rehabilitated, respectively, to of spending on preschool and secondary education is partly due to high capital expenditures required to build accommodate an increased number of students in public secondary schools and reduce the SCR from 158 in 2019 and rehabilitate a large number of classrooms (in comparison to the primary subsector). When considering only to 95 in 2030. 93  But higher than the CEMAC countries average, exclusive of CAR, during the same period (3 percent). 94  This share is a little below the GPE recommended level (45 percent), but the rationale behind this proportion is provided by the following points. 92  In the report A World Ready to Learn, UNICEF (2019) recommends a maximum STR of 20 in pre-primary education. Considering the starting 95  SDG 4 targets universal completion of primary and secondary education by all girls and boys by 2030. Target 1 of SDG 4 reads as follows: “By point (STR = 43 in the public sector) and the limited resources available, however, the target has been set at a lower level (access/quality trade- 2030, ensure that all girls and boys complete free, equitable and quality primary and secondary education leading to relevant and effective 86 off ), closer to the Sub-Saharan average in 2018. learning outcomes” (UNESCO 2020). 87 current expenditures, the share of expenditures allocated to primary education decreases less rapidly, from 38.5 a. The creation of new teacher ranks (see box 4.3) to recruit teachers with different training backgrounds at percent in 2021 to 36.4 percent in 2030 (average of 38.5 percent over 2020–30). lower salaries: (1) agent d’ education, a teaching rank reserved for community teachers are expected to make up a large proportion of the new recruits to be hired in the next decade and would be paid at a lower Lastly, containing spending in the higher education and research subsector is projected to reduce HER spending rate than the two existing teaching ranks at the primary level; (2) professeurs polyvalents du secondaire, from 29.1 percent of the total education budget in 2021 to 17.2 percent in 2030. Nevertheless, despite this high a teaching rank reserved for temporary teachers and existing primary school teachers, whose salaries will reduction in the proportion of total education spending, the level of HER spending will increase by 31 percentage be between that of an instituteur and a professeur de collège. points over the 2021–30 period. b. The introduction of a lower initial salary for maîtres d’enseignements, which would be applicable only to new recruits starting in 2025, as a measure to (1) contribute in setting a more coherent pay scale98 as they 4.5.3. Financing gap are currently paid at a higher rate compared to other civil servants at the same level of qualification; and (2) contain costs of recruiting a large number of teachers. This measure is expected to yield costs savings When adopting the ESP, the government committed to increasing the proportion of spending on education in by reducing the 2030 salary and wages spending at the primary education level by 7.5 percent (that is, total government spending from 13.3 percent in 201996 to 20.1 percent in 2026 (the recommended GPE level) and CFAF 985 million in constant prices); this proportion will increase over the following years, as maitres 23 percent in 2029. Following the COVID-19 pandemic and 2020–21 elections turmoil, it appeared necessary to d’enseignement paid at the salary rate prior to this measure retire and are replaced by new recruits. revise the final target to 22 percent (instead of 23 percent as originally planned) and to postpone its achievement by one year (2030 instead of 2029). According to the baseline scenario, the average annual financing gap over the 4. The launch of a community-based approach to build and rehabilitate classrooms school construction and period 2021–30 then amounts to CFAF 7.4 billion in constant prices (equivalent to US$13.7 million, constant prices). rehabilitation will also yield efficiency gains. This approach has been known to be cost effective as it reduces significantly transaction costs, builds local capacity, and contributes to reducing implementation delays. This financing gap97 for the period 2021–30 is expected to be covered by TFPs. When endorsing the ESP in July 2020, TFPs pledged to support the government in meeting the financing gap through project grants (EBESP, ESPSP, and the Human Capital and Women and Girl’s Empowerment project) and credits (such as the extension of the University of Bangui financed through credit from the Fonds Saoudien). The GPE grant (US$30.85 million) 4.6. RECOMMENDATIONS used to finance the ESPSP covers 56 percent of the average annual financing gap during the 2021–24 period. The proposed recommendations presented in this PER build on the policy reforms that were developed under Assuming there will be additional GPE financing in 2025, while taking into account the grants provided by the ESP and then updated in light of recent events—the COVID-19 pandemic, pre-electoral political measures, other TFPs (including EU, AfDB, AFD, WB, and others), it would be feasible to cover the financing gap to ensure and elections turmoil. Despite these difficulties, the government should now prioritize the implementation implementation of the ESP. Lastly, the proportion of external financing allocated to the education sector, which of the ESP’s recommendations, as they would have a positive impact on the country’s education system. stood at 4.1 percent on average during 2018–20 (see section 4.3.2), will have to increase to 13 percent over the Recommendations under this PER are based on a thorough examination of the many challenges facing CAR’s 2021–30 period (from 6.5 percent to 18.7 percent) to cover the financing gap, which seems realistic given the education system and have been grouped into two categories: (i) high-priority recommendations (table 4.11), and importance of education in consolidating peace efforts in CAR. (ii) additional recommendations to improve the quality, effectiveness, and efficiency of education (table 4.12). 4.5.4. Sustainability of public spending on education High-priority recommendations The fiscal sustainability of the implementation of the ESP reforms to rebuild the education system is taken into account through the following considerations and measures: INCREASE THE SHARE OF SPENDING ON EDUCATION IN THE TOTAL GOVERNMENT BUDGET 1. The commitment of the government to gradually increase the proportion of its total spending in the education Many of the key challenges facing the education sector stem directly and indirectly from underfunding of the sector will provide the funds needed to address sector challenges. Investing in education yields important education sector. The actual government spending on education as a share of GDP stands at only 1.8 percent in benefits such as stability, peace, and social cohesion, which in return reduces spending needs on defense and 2020, which is far below the SSA average of 4.6 percent (see section 4.3.3). To address huge financing needs of public order. the sector (see section 4.5.1), it is imperative that the government effectively prioritizes the education sector in 2. Containing HER spending will allow for a more efficient allocation of the education budget across subsectors its budget allocation process as outlined in the ESP. Thus, education spending should gradually increase from an and will contribute to finance the expansion of the provision of preschool education, secondary education average of 13.3 percent (as a share of total government spending) during 2018–20, to 20 percent (which is the GPE (including TVET), and literacy. recommended level) and beyond if feasible.99 3. The implementation of the overall teacher recruitment strategy (see box 4.1) is expected to lead to a reduction There are three potential ways that the government could consider increasing the allocation of the overall of the average salary of a government-paid teacher at the primary level by 15.2 percent in real terms during budget to the education sector: the next 10 years as result of (a) the previous measures and salary moderation for existing teachers, and (b) 1. Creating fiscal space by improving DRM as discussed under Chapter 2 will in turn make it feasible to increase rejuvenation of the teaching staff due to new recruits. Moreover, the improvement in teacher management the allocation to the education sector. policy also yields important efficiency gains (see section 4.4) that contribute to containing the wage bill. Measures to limit the growth of the wage bill incorporated in the design of the HR policy will have to be 2. Reallocate significant resources away from the defense and public order toward education in order to promote implemented to ensure its sustainability, especially: sustainable growth and peace. Currently, CAR allocates a high share of its resources and number of HR recruitments to the defense and public order sector (see section 4.3.2) due to the fragile security situation. But CAR should gradually reallocate some of this spending to the social sectors, including education, as soon as the 96  The average during 2018–20 was 13.3 percent. 97  The financing gap is the difference between (i) government spending on education financed through domestic resources and budget support 98  The starting gross salaries of the three teaching ranks at the primary level would then amount to CFAF 40,000, 70,000, and 100,000 per and, (ii) total public spending required to address sector needs in order to rebuild the education system based on the targets set under the month. 88 simulation model. 99  In the updated simulation model of the ESP, the 20 percent threshold is reached in 2028 and the target is 22 percent in 2030. 89 security situation improves. This will allow CAR to enter a virtuous circle where more social spending generates HER spending can be reduced by increasing the role of the private sector; thus, would involve (i) developing public- more development and security, which in turn allow to reduce the share of spending on security. In June 2019, private partnerships; and (ii) increasing the financial participation of students in the system costs (see Appendix the IMF launched “A Strategy for IMF Engagement on Social Spending,” which provided a clarification of when A1.2, “Higher education (HER) spending”). and how to engage on social spending (IMF 2019). A core principle of the strategy is that engagement on social spending should be guided by an assessment of its macro-criticality.100 By carrying out this PER, CAR is INCREASE THE PROPORTION OF GOVERNMENT-PAID AND QUALIFIED TEACHERS IN PUBLIC SCHOOLS laying the foundations for the macro-criticality of social spending and thereby highlighting its importance and TO LESSEN THE BURDEN ON POOR COMMUNITIES increasing allocation of the government budget on social sectors. The provision and distribution of qualified teachers paid by the government should be improved to strengthen 3. Leveraging additional resources from TFPs based on the estimated funding gap for the sector (see section 4.5.3) efficiency, equity, and quality of education across the country. To bring the number of students per government- could also be a way to increase spending in the education sector. This implies that funding from TFP should paid teacher to acceptable levels in all prefectures by 2030, the government needs to train, recruit, and deploy many increase overtime through (a) project grants, (b) credits (when appropriate), and (c) more education-targeted teachers throughout CAR. By 2030, the system would continue to rely on (i) the existing teacher cadre, who will be the DPFs (budget support) with better-defined and more effective trigger indicators. A possible way to condition minority of new recruits; and (ii) community teachers, who would have received appropriate training, and be granted DPFs on increased sectoral allocations is to formulate prior actions and triggers (including indicators) in a a more stable status with regular pay borne by the government. Overall, the ESP laid down a set of interrelated way that requires the government to make substantial investments in the education sector. For example, if a strategies to address the lack of qualified teachers at all levels of education (see box 4.1); their implementation condition is set based on the STR of government-paid teachers, then the government will need to pay for more should continue to be the focus of DPFs. Among these strategies, the most critical ones are as follows: teachers to realize the prior action/trigger, hence increasing allocation to the education sector. 1. Implementing as a first step a five-year recruitment plan for all student-teachers who graduated from the IMPROVE THE ALLOCATIVE EFFICIENCY OF THE EDUCATION BUDGET TO ENSURE THAT UNDERDEVEL- teacher training institutes since 2009 and are awaiting integration (see box 4.2). This is a minor measure OPED SUBSECTORS ARE ADEQUATELY FUNDED and a prerequisite to address the shortage of teachers (see section 4.4.3) and make way for further training and recruitment of new teachers. Then, as a second step beginning in 2028, revert back to the practice of A better distribution of the education budget that targets underdeveloped subsectors will contribute to the automatically recruiting student-teachers as soon as they graduate—as contractual teachers for one year, and equity and efficiency of spending. The share of the public spending on education is highly skewed toward higher onboarded into civil service the subsequent year, provided they have performed their applicable duties as a education at the expense of critical subsectors: (i) pre-primary education, literacy, non-formal education and TVET; contractual teacher. The implementation of this plan requires action to restore and secure the budget lines and, to a lesser extent, (ii) general secondary education (which is expanding rapidly without adequate funding). To used to pay for contractual and temporary teachers as in the short run, the system cannot function without improve equity in the distribution of benefits from public education spending, the government should gradually them. increase the share of the education spending allocated to: (i) preschool education from 0.2 percent in 2020 to reach the threshold of 10 percent before the end of the next decade as per the UNICEF recommendation;101 (ii) 2. Increasing and deconcentrating teacher training capacities and recruiting a large number of teachers. This literacy, non-formal education, and TVET through a sustainable financing mechanism by transitioning from a policy involves both increasing the provision of (a) pre-service training, and (b) in-service training, especially project-based financing approach to a systemic model; and (iii) secondary general education, which has a share for new teaching ranks (including training of community teachers in proximity to their schools). It also of only 14.8 percent in 2020. An adequate distribution of the budget should be based on sector priorities and on requires the creation of new lower-cost civil-servant teacher ranks (see box 4.3), that will allow (1) recruitment unit costs to provide consistent and productive service delivery at all levels of education. The most outstanding of teachers with lower qualifications such as community teachers; and (2) offer opportunities to lower-ranked international example of a sectoral performance budgeting system based on unit costs is the “diagnostic related teachers to gradually move up the career ladder, including by providing mobility between different positions group” (DRG) hospital funding system. In education, where costs per student at particular levels of schooling tend and functions. to be relatively standard, unit costs can also be a powerful budgeting and performance management tool.102 3. Improving teacher management through setting up (a) effective deployment mechanisms and The growth of higher education and research spending must be contained, and their sources of financing must incentives, (b) community-based systems to monitor the presence of teachers in schools, and (c) modern be diversified. The share of HER expenditures in the education budget will have to decrease, given that: (i) HER teachers ‘payment methods that will address difficulties in accessing salaries close to teachers’ duty stations. expenditures already take up an extremely large portion of the education budget; (ii) the financing needs of other 4. Remunerating community teachers as a short-term solution in order to lessen the burden on poorer levels of education; and (iii) limited government resources; then. Discussions held with education stakeholders communities. This will require prior identification all existing community teachers in order to avoid windfall during the elaboration of the ESP reveal that it would be politically challenging to cut HER expenditures because effects. of the high influence of both HER students (including strikes and other actions) and political leaders (who are mostly university professors).103 Hence the agreement was reached to significantly reduce the relative share of HER spending in total education spending (see section 4.5.2) without reducing its actual amount. In addition, HER expenditures will be contained through implementing an audit of current expenditures in order to improve TABLE 4.11. THREE PRIORITY RECOMMENDATIONS their efficiency (see Appendix A1.2, “Higher education (HER) spending”). Other containment measures include Proposed reforms Time frame Action: What to do concretely Expected impact Institutions diversifying funding sources through such means as setting up a performance-based contract, carrying out research and consultancy services, and mobilizing funds from the diaspora and external aid organizations. Finally, Increase the Short to • Creating fiscal space to increase spending on Improve access to • Presidency of allocation to the medium education by improving DRM as discussed under education, quality of the Republic education sector term Chapter 2 education, equity in the • MFB/MEPC budget to address • Reallocating significant resources away provision of education, • All ministries 100  “The channels through which social spending may be macro-critical can be grouped into three, often interrelated, channels: Is social spending huge financing from defense and public order sector toward and increased education of education sustainably financed? Is it adequate? Is it efficient? A particular social spending issue is considered macro-critical if one, or any combination, of needs, and reach the education as soon as the national security outcomes for all boys and • TFPs these channels is a policy concern. Or, in other words, social spending is unlikely to be considered macro-critical if it is sustainable, adequate, GPE recommended situation improves girls and efficient under current policies” (IMF 2019). threshold of 20 • Additional resources should be leveraged from 101  “By relying on simulations of strategies allowing for achieving universal access to pre-primary education” (UNICEF 2019). Citation translated percent of the total TFPs based on the estimated funding gap for from the report: « En s’appuyant sur les simulations de stratégies permettant d’atteindre un accès universel à l’enseignement pré primaire ». government budget the sector, through (a) project grants, (b) credits 102  The most outstanding international example of a sectoral performance budgeting system based on unit costs is the “diagnostic related in the medium (when appropriate), and (c) more education- group” (DRG) hospital funding system. In education, where costs per student at particular levels of schooling tend to be relatively standard, unit term, followed by 22 targeted DPFs (budget support) with better costs can also be a powerful budgeting and performance management tool. See Robinson and Brumby (2005). percent by 2030 defined and more effective trigger indicators 90 103  Including the President of the Republic. 91 spending by level of education is an important challenge that constrains the analysis, monitoring, and evaluation Proposed reforms Time frame Action: What to do concretely Expected impact Institutions of overall spending in the sector. For example, it is not currently possible to distinguish MPSE expenditures by Improve the Short to Increase the share of the education spending Develop and improve pre- • MFB level of education (preschool, primary, and secondary); nor is it possible to distinguish METL expenditures (formal allocative medium allocated to: primary education, TVET, • All ministries TVET, non-formal TVET, and literacy).105 Having a budget classification that is clearly structured around the levels efficiency of the term • Preschool education from 0.2 percent in 2020 nonformal education of education of education would facilitate subsector-level analysis and evaluation of the priority areas. education budget to reach the threshold of 10 percent before and literacy, and general to ensure that the end of the next decade as per UNICEF secondary education underdeveloped recommendation Increase efficiency and Improve overall management information systems to ensure efficient use of resources subsectors (pre- • TVET, non-formal education and literacy equity in higher education primary, secondary through a sustainable financing mechanism by and research spending levels including transitioning from a project-based financing TVET, and literacy) approach to a systemic model EMIS are adequately • Secondary general education, which had a share funded of only 14.8 percent in 2020 Strengthening the EMIS capacity by providing adequate technical and financial resources will ensure production The growth of higher education and research of reliable and consistent data for policy making. The annual school census questionnaire is expected to be spending must be contained and their sources of revised to improve the accuracy and quality of the data106 and fill critical information gaps, especially with regards funding must be diversified: to: (i) teachers ranks and functions to allow to identify government-paid teachers, and (ii) actual number of • Conduct an audit of current HER expenditures in order to improve their efficiency physical classrooms and their current usage (single or double shifts). This should be complemented with capacity • Diversify funding sources through such means building to collect data, manage EMIS, and produce timely annual yearbooks and dashboards. as setting up a performance-based contract, carrying out research and consultancy services, mobilizing funds from the diaspora and external HRMIS aid organizations, developing public-private partnerships, and increasing the financial Setting up a HRMIS (as recommended in the ESP) will allow for a better management of education HR, especially participation of students in the system costs with regards to recruitment, deployment, payment, training, and career of teachers. The HRMIS, presented in Chapter 3, will be common to all ministries. In the case of the education sector, it will include all teachers working Increase the Short to long • Implementing a five-year recruitment plan for • Increase number of • MFB proportion of term all student-teachers who graduated from the qualified teachers, • All ministries in the public sector whether they are civil servant teachers or not. This could be done by adding a module on government-paid teacher training institutes since 2009 and are which will contribute of education non-civil-servant teachers, in which there will be information that will allow to monitor the evolution of the and qualified awaiting integration, and reverting back to the to improving access to • School entire teacher workforce because as it is mainly made up of non-civil servants. Overall, the HRMIS should (i) link teachers in public practice of automatically recruiting student- education inspectorates schools to improve teachers (as soon as they graduate) • Reduce inequities in the • Ministry of Civil teachers’ salary payment from the MFB’s payroll system to their presence in their respective duty station, (ii) the quality of • Increasing and deconcentrating teacher training provision of education Service link teacher deployment to the school mapping system under the EMIS, (iii) be accessible and used by SI to allow education and capacities and recruiting a large number of as poor and remote close monitoring of teachers, and (iv) provide detailed information (including pedagogical training received) on reduce the financial teachers, which requires creating new civil- regions will have access burden on families servant teacher ranks to government-paid all categories of teachers. The implementation of HRMIS must be aligned with the implementation of new HR • Improving teacher management through setting qualified teachers management practices. Through HRMIS, it will be possible to set up control and sanction mechanisms, bonus and up (a) effective deployment mechanisms and instead of having to incentives; (b) community-based systems to pay for unqualified hardship allowances, and monitoring of teacher career paths. monitor the presence of teachers in schools, and community teachers (c) modern payment methods for teachers • Improve learning • Remunerating community teachers as a short- outcomes though the Implement the ESP’s strategy with regards to reduction of repetition rates and improve textbook term solution to lessen the burden on poorer availability of qualified policy for better education outcomes communities teachers Potential efficiency savings could be made from the implementation of the ESP’s strategy with regards to reduction of repetition rates. Repetition rates are an important source of internal inefficiency as they contribute to a substantial waste of financial resources, including dedicating classrooms and teachers each year to repeaters, ADDITIONAL CRITICAL RECOMMENDATIONS and increasing dropout rates, overage, STR, and SCR. Many studies have questioned the merits of grade repetition, both on the academic performance of repeaters and on their educational trajectory,107 and found no evidence of its benefits. The ESP strategy consists of progressively eliminating repetition in grades 1, 3, and 5 and reducing Strengthen budget processes for better monitoring and evaluation of spending repetition in grades 2 and 4. This will be done through a mix of administrative measures (that is, establishing an automatic promotion policy in grades 1, 3, and 5) and through providing additional remedial programs to increase Build the capacity of the ministries of education in terms of budget planning and preparation so as to align learning instruction. expenditures with the priorities for the sector as outlined in the ESP. Having the right tools and a full understanding of the budget planning and preparation system is essential. This capacity makes possible expenditure projections, CAR should formulate a national textbook policy as recommended in the ESP in order to (i) reduce unit costs, the elaboration of specific budget proposals to the MFB, and negotiations for appropriate resource allocation for and (ii) ensure the availability of textbooks in schools. As a first step, the methods of transportation and the sector when the budget circular104 is issued. Improving the capacity of the education ministries will help in management of textbook stocks must be assessed and revised. Second, a study on a textbook policy adapted to achieving the targets set under the ESP for each subsector. Financing needed to achieve these targets has been laid out in the ESP simulation model, which serves as an expenditure planning tool. This will help in avoiding erratic allocations that do not allow for the sustainability of strategies and the achievement of targets. Reflect the allocation of spending to each level of education separately and clearly in the functional classification 105  In this PER, an algorithm was constructed based on the wages and salaries spending recorded under the payroll system in order to distinguish spending by level of education. See Appendix A1.2, “Methodology to breakdown government spending by sectors.” of the budget, to allow better monitoring and evaluation of spending. The lack of a clear classification of education 106  The accuracy sought concerns information on (i) both the grade and category of teachers to clearly identify those paid by the government, (ii) secondary and higher education teachers working both in the public and private sectors to know the real number of teachers in the system, and (iii) information on physical classrooms and their use (single or double shift). For more details, see section V.3.2 of the Central African Republic Education Sector Plan 2020–2029. 92 104  A document issued by the Central Budget Authority to guide line ministries and agencies in the preparations of their initial budget proposals. 107  See UNESCO (2012) and Marsico Institute (2012). 93 the Central African context must be carried out. For example, CAR could learn from Djibouti’s methods.108 Djibouti’s REFERENCES Center for Research, Information and Production of National Education designs and publishes its own textbooks rather than using an international publisher, and it can then print them at low cost abroad. Third, an audit of the Agence Française de Développement (AFD). 2018. “National Strategy for Technical Education and Vocational textbook purchases and the development of price guidelines for future purchases should be conducted by the Training in the Central African Republic (SNETFP).” AFD, Paris. Regulatory Authority Public Procurement. Then, a holistic textbook policy should be developed which will focus Bruns, Barbara, Alain Mingat, and Ramahatra Rakotomalala. 2003. Achieving Universal Primary Education by 2015: on (i) providing each student with a sufficient number of textbooks for basic subjects (reading, mathematics, A Chance for Every Child. Washington, DC: World Bank. © World Bank. https://openknowledge.worldbank.org/ science) according to teaching priorities;109 (ii) drastically reducing unit costs of textbooks, especially by publishing handle/10986/15121 License: CC BY 3.0 IGO. textbooks according to international procurement rules and by printing books in batches; and (iii) packaging, International Monetary Fund (IMF). 2019. “A Strategy for IMF Engagement on Social Spending.” Policy Paper No. distributing, and then using effectively textbooks to enhance teaching and learning. In the medium term, when 19/016. IMF, Washington, DC. the introduction of Sango in the first years of elementary school and the development of a structured pedagogy are advanced enough (and the pace of learning is stabilized110), then investments in textbooks based on an updated ———. 2020. “IMF Country Report No. 20/1.” January 2020. IMF Washington, DC. https://www.imf.org/en/ curriculum and the textbook policy should be considered. Publications/CR/Issues/2020/01/13/Central-African-Republic-Request-for-a-Three-Year-Arrangement-under- the-Extended-Credit-48940. Jaramillo, A., and A. Mingat. 2008. “Can Early Childhood Programs Be Financially Sustainable in Africa?” In M. Garcia, TABLE 4.12. THREE ADDITIONAL CRITICAL RECOMMENDATIONS A. Pence, & J. L. Evans (Eds.), Africa’s Future—Africa’s Challenge: Early Childhood Care and Development (ECCD) in Sub-Saharan Africa, 459–85. Washington, DC: World Bank. Proposed reforms Time frame Actions Expected impact Institutions Marsico Institute. 2012. “Does Retention (Repeating a Grade) Help Struggling Learners.” https://www.du.edu/ marsicoinstitute/media/documents/Does_Retention_Help_Struggling_Learners_No.pdf. Strengthen budget Short term • Build the capacity of the ministries of More effective • MFB/MEPC processes for education in terms of budget planning allocation of the • All ministries of MEPSTA (Ministère de l’enseignement primaire secondaire technique et de l’alphabétisation). 2018. “ Des better monitoring and preparation so as to align the budget between education mécanismes d’adaptation négatifs comme l’adhésion à des groupes armés, le recours à la drogue et la participation and evaluation of priorities for the sector as outlined in subsectors and spending the ESP with the budgeting process. between activities, in à d’autres activités criminelles“ Programme Pluriannuel de Résilience (Multi-Year Resilience Programme) 2019– • Reflect allocation of all spending to line with the sector’s 2021; p.1–2. each level of education separately to medium- and long- MPSE, MPSTA, MSRTI, and MES. 2020. “Plan Sectoriel de l’Education 2020-2029.” https://planipolis.iiep.unesco. allow better monitoring and evaluation term strategies of spending. org/en/2020/plan-sectoriel-de-l%E2%80%99%C3%A9ducation-2020-2029-7056 Organisation for Economic Co-operation and Development (OECD). 2018. “Engaging Young Children: Lessons from Improve overall Short term • Strengthen the EMIS capacity by Improved • MFB/MEPC Research about Quality in Early Childhood Education and Care.” Starting Strong Report Series, OECD Publishing, management providing adequate technical and management of the • All ministries of Paris. information financial resources will ensure sector (HR, school education systems to ensure production of reliable and consistent mapping, and so Primature Comité d’Organisation du Forum National sur l’Education. 2008. “Rapport General du Forum National efficient use of data for policy making. forth) and budgetary sur l’Education.” République du Mali, Bamako resources • Set up a HRMIS for better management oversight of recruitment, deployment, payment, Pompa, Claudia. 2014. “TVET and Skills Training in Fragile and Conflict Affected Countries.” Overseas Development training, and career of teachers. Institute (ODI). https://assets.publishing.service.gov.uk/media/57a089eb40f0b6497400030e/TVET_and_skills_ training_in_fragile_and_conflict_affected_countries_60.pdf. Implement the Short to • Implement the ESP’s strategy with Improved quality of • MFB ESP’s strategy medium term regards to reduction of repetition education • All ministries of Rawkins, Christa. 2019. “A Global Overview of TVET Teaching and Training: Current Issues, Trends and with regards rates, which consists of eliminating education Recommendations.” Report submitted to the 13th Session of the Joint ILO–UNESCO Committee of Experts on the to reduction of repetition in grades 1, 3, and 5 and • School Application of the Recommendations concerning Teaching Personnel (CEART). repetition rates reducing repetition in grades 2 and 4. inspectorates and improve • Formulate a national textbook policy Robinson, Marc, and Jim Brumby 2005. “Does Performance Budgeting Work? An Analytical Review of the Empirical textbooks as recommended in the ESP in order Literature.” International Monetary Fund Working Paper WP/05/210. IMF. Washington, DC. policy for better to reduce unit costs and to ensure the education availability of textbooks in schools. Snower, Dennis J., 1994. “The Low-Skill, Bad-Job Trap.” IMF Working Paper No. 94/83. Available at SSRN: https://ssrn. outcomes com/abstract=883810. United Nations Children’s Fund (UNICEF). 2019. “A World Ready to Learn: Prioritizing Quality Early Childhood Education.” UNICEF, New York. United Nations Educational, Scientific and Cultural Organization (UNESCO). 2012. “Opportunities lost: The Impact of Grade Repetition and Early School Leaving.” Paris: UNESCO. IS/2012/ED/SD/08. ———. 2020. “SDG 4: Education.” In 2020 Global Education Monitoring Report Team (GEM Report). Paris: UNESCO. https://fr.unesco.org/gem-report/node/1346. United Nations Office for the Coordination of Humanitarian Affairs (OCHA). 2021. “Central African Republic Situation Report.” Last updated: 26 Jan 2021. Available at: https://reliefweb.int/sites/reliefweb.int/files/resources/ Situation%20Report%20-%20Central%20African%20Republic%20-%2022%20Jan%202021.pdf.OCHA World Bank. 2011. Learning for All: Investing in People’s Knowledge and Skills to Promote Development—Education Strategy 2020. Washington, DC: World Bank. 108  See https://www.manuelscolaire-cripen.com/. 109  To this end, it will be necessary to set the textbook-to-student ratio for each level. These ratios are expected to eliminate inequalities between regions. 94 110  It is probable that these measures will significantly accelerate the pace of learning compared to current situation. 95 CHAPTER 5. HEALTH111 The author of the health chapter is Soazic Elise Wang Sonne. Moulay Driss Zine Eddine El Idrissi and Mahoko 111  Kamatsuchi provided valuable comments. 96 97 5.1. INTRODUCTION 5.2. STRUCTURE AND ORGANIZATION OF THE HEALTH SECTOR This chapter provides an overview of the patterns and composition of health spending in CAR, in terms of CAR is divided into 16 communes and 35 health districts grouped into 7 health regions with the health region adequacy, effectiveness, efficiency, and equity. We analyze the ability of health spending and other health number 7 representing the City of Bangui. The latter has the densest health districts of up to 24,272 inhabitants inputs to improve health outcomes of the most vulnerable populations, namely women and children. per square kilometer (km²), far above the country’s average density of 8 inhabitants per km². Ten health districts outside the city of Bangui have more than 15 inhabitants per km². The North-eastern part of the country, controlled The core objectives of this chapter are to: (i) assess the progress of CAR toward achieving universal health coverage by terrorist groups during the 2012 violent conflict, remains underpopulated with a density of 1 inhabitant/km2: as compared to countries of a similar socioeconomic status; (ii) assess the level of equity in the distribution and five health districts located in the East and North-eastern parts of the country have less than 5 inhabitants per access to health resources, utilization, and services; (iii) assess the level of equity and efficiency in the allocation km². The organization of the CAR’s public health system is pyramidal with three levels: central, intermediate, and of health financing resources, and; (iv) suggest key policy recommendations to improve sustainable financing of peripheral, as summarized in figure 5.1 below. the health sector in the midst of the COVID-19 pandemic. The chapter presents status and trends in health outcomes and health spending, highlights the main challenges in the CAR health sector, and draws policy recommendations on how to improve the efficiency and sustainability FIGURE 5.1. ORGANIZATION OF CAR’S PUBLIC HEALTH SYSTEM of health spending under fiscal stress exacerbated by the COVID-19 pandemic. On the latter, the chapter discusses implications of COVID-19 for health financing in the country under different scenarios and provides key policy recommendations for the government. The chapter also reviews the national results-based financing (RBF) strategy, which was introduced and supported by World Bank health projects (Health System Support project Ces 35 districts sanitaires sont gérés par (PASS) (P119815) and the Health System Support and Strengthening Project (SENI) (P164953) and the European des Equipes de Cadre de District (ECD). PÉRIPHÉRIE : Union. The main objective was to improve the quality and utilization of essential health services at the health 35 Districts facility level with an overarching goal of strengthening health services delivery throughout the country. Service sanitaires improvement should ultimately improve health outcomes for the population, including by providing free health Les sept Régions sanitaires sont chargées du care, especially for children and women including GBV survivors. suivi et de la mise en œuvre des politiques définies au niveau central et de l’appui technique INTERMÉDIAIRE : The chapter is divided into eight core sections as follows: (i) Overview of the health sector in CAR including existing aux districts sanitaires (niveau opérationnel). 7 Régions sanitaires government health policies, plans, and strategies; (ii) Presentation of the structure and organization of the health sector; (iii) Status and trends in health outcomes and inputs at the national, regional, and subnational levels; Responsable de la conception, de la (iv) Trends, level, structure, and composition of health spending; (v) Financial protection and equity in health coordination et de la supervision des CENTRAL : outcomes and access to health services; (vi) Implications of COVID-19 for health financing in CAR; (vii) Overview politiques générales du secteur ainsi que des actions nationales. Centres de santé, Postes de santé of Results Based Financing (RBF) in the health sector in CAR; and (viii) Conclusion and policy recommendations. We rely on the most recent sources of data available, coming from the following surveys: the Multiple Indicator Cluster Surveys (MICS) 2018–2019; the CAR National Health Accounts 2015–2018 released in 2021 by the Ministry of Health; the Institute of Health Metrics (IHME), the WHO Global Expenditure Database; the World Development Indicators (WDI); the SARA-HeRAMS surveys; and the 2019 Health System Mapping (Carte sanitaire). The central level is made up of (i) health centers covering an area of 10,000 inhabitants on average and health posts, which are annexes of health centers. Health centers ensure the Minimum Activity Package (MAP) and refer 5.1. OVERVIEW OF THE HEALTH SECTOR IN CAR INCLUDING EXISTING patients to a secondary hospital (HS) or to the district hospital (DH), which represents the first level of reference for health centers. The second level of reference is represented by regional university hospitals (RUH), which GOVERNMENT HEALTH POLICIES, PLANS, AND STRATEGIES ensure the activities of the Complementary Activity Package of the district hospital and some specialized care. The referral is made to central offices of hospitals of the capital and the counter-reference of district hospital. At the The implementation of health sector policies reforms initiated since 2019 has been carried over in 2020 and national level, there are diagnostic and public health care structures made up of four health care establishments early this year, although slightly halted by the COVID-19 pandemic. Five main policies and strategies are guiding and three diagnostic facilities. They constitute the tertiary level. government’s actions in the health sector, namely: (i) The 2019 National Health Development Plan; (ii) the National Health Financing Strategy, validated in November 2019 and yet to be finalized; (iii) the National Maternal-Child, In 2018, of the 1,014 total health facilities listed in the National Health mapping card (Carte sanitaire), 853 were Reproductive and Adolescent Health and Nutrition Investment Case (IC) 2020–2022 (January 2020), which is listed as functional and roughly 16 percent (161) were nonfunctional; and four of CAR’s five central hospitals being updated with the new MICS 2019 data; (iv) the 2019–2023 National Strategy for the fight against Gender- are in Bangui. In 2019, the updated WHO SARA/HeRAMS survey listed a total of 873 functional health facilities, based violence, Child Marriage and Female Genital Mutilation, which was also adopted in 2019; and (v) the National consisting mainly of 434 health posts (50 percent), 387 health centers (44 percent), and 52 hospitals112 (6 percent). Policy for the Promotion of Equality and Equity (drafted December 2019). This equates to 0.1 hospitals, 0.7 health centers, and 0.8 health posts per 10,000 people. The most populated health region 3, with 20 percent of the population, has the highest number of health facilities, 199 (23 percent) Work still needs to be done on a realistic national pharmaceutical and supply chain strategy, a consolidated compared to health region 7 with only 7 percent of health facilities. national community health service delivery policy, and other key elements of the health sector. In July 2020, the United Nations and its partners updated the Humanitarian Response Plan in CAR, mobilizing US$152.8 million to Some functional health facilities were partially destroyed (and a few fully destroyed) during violent conflict address the most immediate and critical health and non-health needs of the millions of Central Africans affected in 2012–15. Of the 853113 functional health facilities surveyed under the 2019 WHO SARA, 14 percent (120) were by the consequences of COVID-19. The government recently allocated US$2.7 million from their national 2021 partially destroyed and roughly 1 percent (8) were fully destroyed during the 2012–15 conflict. Close to half (49 budget for routine childhood vaccination procurement, which was unprecedented progress in the health sector. The government launched a routine immunization revival plan which will extend over a two-year period (2020– 22) with the objective of mobilizing CFAF 11 billion to achieve a vaccination coverage rate of around 90 percent 112  These are central hospitals, regional hospitals, district hospitals and secondary hospitals. 98 within three years in CAR. 113  A sample representing 98 percent of the total number of health facilities nationwide. 99 percent) of the 174 health facilities listed as nonfunctional in the survey were fully destroyed and up to 21 percent FIGURE 5.3: TREND IN HEALTH OUTCOMES INDICATORS IN CAR (37) were still intact. Facilities that are intact but still not functional—mainly located in health regions 2, 6, and 8— should be rehabilitated as soon as possible to address the challenges in health services delivery. Many functional 1600 100 health facilities in CAR still lack access to basic infrastructure, with 68.8 percent having no access to any source of Maternal Mortality Ratio (Per 100,000 live birth) Infant Mortality Ratio ( Per 1000 live births) 90 energy and 43.3 percent having no access to any source of water. 1400 80 1200 There is an uneven distribution of health facilities across regions based on the population and the density per 70 km2. As figure 5.2 shows, health region 5, although representing only 4.7 percent of the total population in CAR, 1000 60 has an average of 2.9 health facilities per 10,000 inhabitants, above the norm of 2 health facilities per 10,000 800 50 inhabitants recommended by the WHO. Also, health regions 5 and 6 have less than one facility per 1,000 km2, 40 health regions 1, 2, 3, and 4 have approximately 1 to 2 facilities per 1,000 km2; while health region 7 alone (Bangui) 600 30 has 567 facilities per 1,000 km2. 400 20 200 10 FIGURE 5.2. SHARE OF HEALTH FACILITIES PER REGIONS BY TYPE AND BY POPULATION SIZE 0 0 2011 2014 2015 2013 2012 2016 2019 2021 2018 2010 2017 2020 2011 2014 2015 2000 2007 2013 2012 2016 2019 2018 2001 2004 2010 2017 2005 2003 2002 2006 2009 2020 2008 Africa Western and Central Sub-Saharan Africa Africa Western and Central Burkina Faso 140 1,200,000 3.50 25% Burkina Faso Central African Republic Central African Republic Ethiopia Chad Ethiopia Mali Mozambique SHARE OF THE TOTAL POPULATION (IN %) 2.90 120 3.00 Mali Mozambique Niger Sudan 1,000,000 20% NUMBER OF HEALTH FACILITIES Niger Sudan Sub-Saharan Africa Chad TOTAL HEALTH FACILITIES PER 10,000 INHABITANTS 100 2.50 POPULATION IN CAR 800,000 80 2.00 1.90 15% 80 72 2.00 1.80 1.80 Source: World Development Indicators (WDI). 61 61 600,000 1.40 60 1.50 49 10% 44 400,000 1.00 Key health outcomes in CAR and access to basic health care services also remain low when compared with key 40 0.60 5% regional groups and populations, namely, CEMAC, SSA, FCV and LIC in 2018 (figure 5.4). 20 200,000 20 0.50 0.00 0% 0 RS 1 RS 2 RS 3 RS 4 RS 5 RS 6 RS 7 0 RS 1 RS 2 RS 3 RS 4 RS 5 RS 6 RS 7 FIGURE 5.4: COMPARISON OF KEY HEALTH OUTCOMES INDICATORS IN CAR WITH REGIONAL HEALTH REGIONS HEALTH REGIONS AVERAGES Hospital Health center Health facilities per 10000 inhabitants Health Post Population share in the total population 0.77 LIC 0.66 0.93 LIC Source: 2019 SARA/HeRAMS Survey. RS = région sanitaire (health region). 0.77 FCV 0.68 0.94 FCV 0.73 5.3. TRENDS AND STATUS IN HEALTH INPUTS AND OUTCOMES IN CAR SSA 0.68 0.93 0.70 SSA 5.3.1. Trends in health outcomes CEMAC 0.70 0.92 Over the past decades, there have been small improvements on key health outcomes in CAR, but such progress 0.59 is still low with regards to relevant comparators and the regional average in Sub-Saharan Africa (SSA). Under CAR 0.59 CAR five years old and infant mortality ratio still remain high, still at more than 100 per 1,000 live births (resp, more 0.88 than 70 per 1,000 live births) since 2013, a higher rate than SSA and all relevant comparators, namely Burkina Faso, 0.00 0.50 1.00 0 20 40 60 80 100 Ethiopia, Mali, Mozambique, Niger, Sudan, and Chad. Maternal mortality, although falling from 1,280 per 100,000 Adult survival rate Fraction of children not stunted Birth attended by skilled staff Antenatal care live births in 2000 to 829 per 100,000 live births in 2017, is still higher than in all comparators and SSA, except for Probability of survival to age 5 Modern contraception use (DPT3) vaccination Chad. CAR also has one of the highest prevalence rates of stunting in SSA, estimated at 40.8 percent for children under the age of five in 2018, far above the Sustainable Development Goal (SDG) target of 29 percent. Figure 5.3 suggests that health outcomes in CAR remain low despite the noticeable progress on key health outcomes Source: WDI and CAR 2018 MICS survey. indicators over the past 25 years. 100 101 Differences across regions also shows large inequalities in access to health services between the capital Bangui Inequalities in access to and utilization of health services across geographical locations (urban vs rurals) and and its suburbs (Region7) where health service coverage is higher than the rest of the country. This suggests income levels are also significant. Low-income women and children, as well as those living in rural areas, fare inequity in health outcomes and access to health services (See figure 5.5 below). much worse than those who are better-off or settled in urban areas. For instance, while 33 percent of the poorest women have no access to antenatal care, only 3 percent among the wealthiest women are in this situation; for family planning, these figures are 33 percent (wealthiest) and 12 percent (poorest) (Figure 5.6 below). Similarly, FIGURE 5.5. STUNTING AND MORTALITY FOR CHILDREN UNDER FIVE BY REGIONS children born in wealthier households are three times more likely to be vaccinated (DPT3) and twice less likely to be stunted than those in poor households, with similarly large gaps observed to the detriment of children in rural areas. 140 60 120 U5 MORTALITY RATE PER 1,000 LIVE BITHS 120 100 50 FIGURE 5.6. STUNTING AND MORTALITY FOR CHILDREN UNDER FIVE BY REGIONS 98.6 98.6 100 80 STUNTING RATE IN % 40 (a) Use of family planning, facility-based deliveries, (b) Stunting, DPT3 vaccine coverage, and access to 83.2 PERCENTAGE 80.4 77.6 76.4 76 80 and access to antenatal care for women diarrhea treatment for children under five 69.3 69.4 60 67.5 30 60 49.3 40 46.7 20 41.1 40.4 Children Children under under 29% 29% 36.5 36.5 40 33.6 33% 33% 31.6 Use ofof Use any any Family Family 5 who 5 who received received 21% 21% 29.6 28.8 20 10 Planning PlanningServices Services for for 12%12% whichever whichever form form 31% 31% 20 married 15-49 15-49 married in in oror ofof ORS ORS 28.8% 28.8% 20% 20% 11.9 0 union union women women 12% 12% 0 0 RS1 RS2 RS3 RS4 RS5 RS6 RS7 RS1 RS2 RS3 RS4 RS5 RS6 RS7 HEALTH REGIONS Children 11% Children 11% under under 5 who 5% 5 who 5% HEALTH REGIONS (DPT3) vaccination Antenatal care (at least one visit) received received ORSORS 11% 89% 89% 11% U5 Mortality Rate Stunting Birth attended by skilled staff Birth Birth a health in in a health and and Zinc Zinc 7%7% 39% 39% facility facility (15-49 (15-49 pregnant pregnant women) women) 82% 82% 48% 48% 24% 24% Source: 2018 MICS survey. Stunting Stunting 44% 44% (Children (Children under under 5) 5) 30% 30% 44% 44% 3%3% No access No toto access 33% 33% Antenal Antenal Care (15-49 (15-49 Care Children Children (12-23 (12-23 64% 64% 7%7% pregnant pregnant women) women) months) months) who who 21% 21% 27% 27% received received the the 51% 51% DPT3 DPT3 Vaccine Vaccine 28% 28% 0% 0% 50% 50% 100% 100% 0% 0% 50% 50% 100% 100% Income Income Group Group Wealthiest Wealthiest Income Income Group Group Poorest Poorest Income Income Group Group Wealthiest Wealthiest Income Income Group Group Poorest Poorest Place Place ofof Residence Residence Urban Urban ofof Place Place Residence Residence Rural Rural Place Place ofof Residence Residence Urban Urban ofof Place Place Residence Residence Rural Rural Source: 2018 MICS survey. Both supply- and-demand-side constraints contribute to poor health outcomes in CAR. Supply-side barriers are related to the availability and quality of care (medical supplies, human resources for health, infrastructure) and demand-side constraints include financial resources, namely household expenditure. Supply- and demand- side factors affect households’ decisions to seek preventive or curative health care in CAR and contribute to the differences in health outcomes observed across regions and population groups. The prevalence of communicable diseases in CAR such as diarrhea (ranked first on the total burden of diseases per disability-adjusted life years [DALYs]) and malaria (ranked fifth on the total burden of diseases per DALYs) remained high. CAR has one of the highest levels of diarrheal diseases in SSA, largely surpassing countries from a comparable standard of living (figure 5.7). 102 103 FIGURE 5.7. GLOBAL BURDEN OF DISEASES IN CAR BASED ON DALY AND NUMBER OF DEATHS 5.3.2. Supply-side constraints IN 1990 AND 2019 Availability of health infrastructure is low with the density of health facilities estimated on average at 1.6 health facilities per 10,000 inhabitants. National hospital capacity is also low with only 13 beds per 10,000 inhabitants and 7 beds for 1,000 pregnant women. In health regions 1, 2, and 7, the service operational capacity index is 50 Central African Republic Both sexes, All ages, DALYs percent. The most available items are equipment (74 percent) and standard precautionary measures (72 percent). Essential drugs (27 percent) and diagnostic capacity (37 percent) are less available. The maternal, child, neonatal, and adolescent health services (SMNIA) have availability of between 61 percent for childhood immunizations and 87 percent for preventive and curative care for children. Health facilities offering maternal, neonatal, and child health (MNCH) services have a good operational capacity for childhood immunization with a score of 77 percent. CAR like many developing countries in SSA has a serious shortage of qualified health workers, including their uneven geographical distribution and insufficient training. Moreover, their salaries remain low, adversely affecting their motivation and performance. International migration, career changes among health workers, premature retirement, morbidity, and premature mortality are often cited as the main reasons behind the shortage of health workers in CAR114. According to the latest 2019 SARA/HeRAMS survey, there is an acute shortage/lack of health workers (including doctors, obstetric care workers, nurses, and midwifes) who are unevenly distributed across the 7 regions of the country, with a greater concentration of health workers in region 7 (Bangui). The survey also shows that there are only 7.3 health professionals per 10,000 inhabitants in CAR (0.8 general practitioners [doctors], 2.5 nursing professionals, 2.4 other nursing professionals, 1.6 obstetric care professionals), which is far below the WHO standard of 23 health workers per 10,000 inhabitants. Despite the relatively low under-five years mortality rate in region 7 (Bangui) in 2019 (59.5 per 1,000 live births), this region has the largest number of health professionals, with 30.8 total health workers per 10,000 inhabitants (including 8.5 nursing professionals per 10,000 inhabitants), well above the WHO standard of 23. This is much higher than the ratio of 1.3 total health workers for the most populated region 3, which has one of the highest under-five mortality rates in CAR of 105.10 deaths per 1,000 live births. Also, Bangui (region 7) has the highest share of obstetric care workers per 10,000 pregnant women (5.8 obstetric care workers per 10,000 inhabitants or 144 obstetric care workers per 10,000 pregnant women), despite having the lowest total fertility rate (3.8 children per woman). By contrast, region 3 with the highest total fertility rate in 2019 (7.3 children per woman) only has roughly 0.4 obstetric care workers per 10,000 inhabitants or approximately 9 obstetric care Central African Republic workers per 10,000 pregnant women (figure 5.8). Both sexes, All ages, Deaths FIGURE 5.8. DISTRIBUTION OF HEALTH WORKERS PER 100,000 INHABITANTS WITH U5 MORTALITY RATE 140 RS 4 U5 years old mortality rate 120 RS 6 100 RS 7 RS 1 80 RS 2 60 40 RS 3 RS 5 20 0 0 5 10 15 20 25 30 35 Health workers per 10,000 inhabitants Source: SARA/HeRAMS 2019 survey and 2019 MICS survey. RS = région sanitaire (health region). There is strong inequality in the distribution of human resources in CAR. Region 3 is the most populous health region with 20 percent of CAR’s inhabitants. It has the third highest rate of under-five mortality (105.1 per 1,000 live births, roughly 1.7 times higher than in Bangui), and the third highest stunting rate (41 percent, 20 percentage Source: Global Burden of Diseases Country Profile, IHME 2020. 104 Note: The DALY combine estimates of the years of life lost (YLL) and years lived with disabilities (YLD). 114  See https://www.who.int/workforcealliance/countries/caf/en/. 105 points higher than in Bangui). On the other hand, region 3 has twice the number of functional health facilities per distribution of CHWs by regions. One of the most immediate priority actions the government should undertake 10,000 inhabitants as Bangui, including the highest number (129) of function health posts (roughly 14 times more is filling the gaps of CHWs in regions with poorer health outcomes and with the lowest share of CHWs per capita. than Bangui), 9 functional hospitals (5 more than Bangui), 61 functional health centers (17 more than Bangui). CHWs also suffer from insufficient equipment and supplies to carry out their roles. In 2019, the Government But region 3 only has 1 health professional per 10,000 inhabitants, (0.7 nurses per 10,000 inhabitants and only elaborated a National Community Health Policy for 2020–2030, which aims to empower communities to improve 0.2 doctors per 10,000 inhabitants). Bangui has 8.5 nurses and 3.6 doctors per 10,000 inhabitants, for a total of 31 their health and bring health care services closer to the population. A detailed analysis and costing of the CHW health professionals per 10,000 inhabitants (Data from SARA/HeRAMS Survey 2019). policy is done in the Annex (See Box A.3.3). More obstetricians are needed in regions 3, 4 and 6 to prevent neonatal disorders, which are ranked 2nd in CAR’s Global Burden of Diseases based on DALYs. In these three regions, the under-five mortality rate is 1.5 times higher 5.3.3. Demand-side constraints than in Bangui; but there is less than 1 obstetric care professional per 10,000 inhabitants, compared to around 6 obstetric care professionals per 10,000 inhabitants in Bangui. From 2008 to 2018, out-of-pocket payments accounted for roughly 40 percent of funds supporting the health care system in CAR, reaching up to US$22.4 per capita in 2018. Challenges in access to health services are disproportionately concentrated among the poorest households. Large out-of-pocket costs and limited insurance coverage (with roughly 1 percent of the population covered by any form of social insurance according to the 2018 TABLE 5.1: HEALTH WORKERS, BED CAPACITY, AND HEALTH FACILITIES PER 10,000 MICS) constitute the major barriers for access to health services across the country. A new free health care policy INHABITANTS IN CAR was launched in February 2019, which targets the most vulnerable groups (mainly children under the age of five, pregnant women and GBV survivors). This policy is expected to increase demand for health services and reduce obstetric care professionals professionals Other health U5 Mortality the heavy financial burden of health-related expenditures on household budgets. U5 Stunting inhabitants inhabitants inhabitants inhabitants inhabitants inhabitants inhabitants live births) per 10,000 per 10,000 per 10,000 per 10,000 per 10,000 per 10,000 (per 1,000 facilities workers Doctors Bed per Nurses 10,000 Health Health Other Lack of education (especially among women), location, and conflict are other barriers for accessing health (in %) care services. MICS 2018 data suggest that women with a post-primary level of education (“fundamental 2” and higher) were 21.2 percentage points more likely to have received antenatal care services. Moreover, people living RS 1 4 0.5 0.3 1.9 1.6 12 2 101.5 39.7 outside of Bangui have difficulty accessing services due to lack of paved roads. In some eastern part of the country RS 2 3 0.2 0.3 1.3 0.9 15 1 81.6 47.7 plagued by violent conflict, there is a high level of insecurity preventing users from travelling to health facilities. RS 3 1 0.2 0 0.7 0.4 18 2 105.1 41 Finally, socio-cultural constraints, in particular traditional harmful health practices, are another major obstacles RS 4 2 0.2 0.1 1.3 0.7 4 2 122.6 39.6 for accessing basic health services such as nutrition and reproductive health. Even though the practice of traditional medicine is officially accepted,115 some traditional healers only referred patients to medical services in RS 5 3 0.4 0 1.9 0.7 9 3 74.4 31.3 cases of serious illness (Ministry of Health and Population 2019). RS 6 1 0.2 0 0.6 0.2 9 2 108.2 43.1 RS 7 31 3.6 13 8.5 5.8 15 1 59.5 21 5.4. TREND, SOURCES, AND COMPOSITION OF TOTAL HEALTH Source: 2019 SARA/HeRAMS Survey and MICS survey. EXPENDITURES IN CAR A disaggregated analysis of health workers by gender and place of residence shows that some health regions 5.4.1. Total health expenditures (number 2, 3, 5 and 6) have no female medical doctors on the payroll in 2020. The government’s ability to deploy health workers outside of Bangui is weak due to the absence of motivation 5.4.1.1. TREND OF TOTAL HEALTH EXPENDITURES and the lack of financial incentives. There are no special allowances granted to health workers who work in remote areas. Health workers benefit from allowances on top of their base salary which do not significantly vary across Total health expenditures remain low in CAR despite the more than twofold increase of roughly 180 percent regions. There are no significant differences in health workers’ gross salaries or allowances between those working from CFAF 50.53 billion in 2015 to CFAF 141.71 billion in 2018. With the slow population growth rate over the in Bangui and outside Bangui in conflict-prone remote rural areas. For instance, in 2020, a medical doctor working same period, this has translated to an equivalent per capita rise of 170 percent from CFAF 11,247 in 2015 to CFAF in Bangui earns on average CFAF 319,808.1 per month, which is close to what a medical doctor working in a conflict 30,368. In the meantime, the share of total health expenditures at only 5 percent of the GDP in 2015 rose to 11 prone area such as Basse-Kotto will also earn (CFAF 315,052). Overall, the Health Ministry’s wage bill is relatively percent in 2018, a level far above regional averages in FCV and SSA as well as CAR’s relevant comparators countries. small accounting for only 5.1% of the total public service wage bill (compared to 18.3% for education and 33.9% for The two main major sources of funding for total health expenditures in CAR are external donors and out-of- national defense) and for only 5.9% of all public servants in 2020 (21% for education and 40% for national defense). pocket payments from households, together paying for more than 88 percent of total health expenditures since A detailed table of the health sector’s wage bill is available in the Annex (See tables A.3.16, A.3.17 & A.3.18) 2015. A categorization by structure suggests that total health expenditures are essentially made up of current health expenditures (on average more than 98 percent of total health expenditures from 2015 to 2018) and capital There is still a limited coverage of community-based interventions in CAR despite the extensive evidence health expenditures (less than 2 percent over the same period as illustrated in figure 5.9). However, capital health base showcasing the potential of Community Health Workers (CHWs) to enhance health services delivery in spending has been progressing from only 0.2 percent of total health expenditures in 2015 to 1.8 percent in 2018. remote rural areas. CHWs have the potential to raising awareness for women and children to obtain essential The volume of capital health expenditures in CAR has also been rising exponentially, reaching CFAF 2.5 billion in health services and deliver high-impact and cost-effective services. A recent situational analysis of community 2018, 25 times the amount in 2015, whereas current health expenditures in 2018 were roughly three times the health programs in CAR found that most are funded by donors and are fragmented. CAR has a number of CHWs amount in 2015. operating in rural areas, but this cadre lacks reference documents outlining their roles and responsibilities, areas of intervention, package of services, and incentives. Based on recent estimates from the Ministry of Health, there is a total of 5,070 CHWs in CAR, equivalent to roughly 1 CHW per 1,000 inhabitants. Table A.3.19 in Annex presents the In September 2020, the Ministry of Health reaffirmed their support and engagement towards traditional healers by pushing for the 115  106 implementation of traditional medicines and pharmacopoeia within the framework of the health system. 107 FIGURE 5.9. TREND IN CURRENT AND CAPITAL HEALTH EXPENDITURES IN CFAF BILLIONS, 5.4.1.2. SOURCES OF FUNDING OF TOTAL HEALTH EXPENDITURES BY TYPE OF EXPENSES (CURRENT VS 2015–18 CAPITAL HEALTH EXPENDITURES) 160 2.0% Current health expenditures 141.7 140 1.8% 1.8% 1.6% External donors, the government, households’ out-of-pocket payment spending, and other domestic private 120 1.4% payments are the four main sources of financing of the health sector in CAR (see table A3.4 in the Appendix 100 80.6 1.2% A3). From 2012 to 2018, more than 78 percent of current health expenditures in CAR have been funded by external 80 59.1 1.0% donors and/or household out-of-pocket payments. From 2012 to 2017, direct out-of-pocket (OOP) payments 50.6 0.8% from households were the top health financing source in CAR (more than 44 percent of total current health 60 0.3% 0.6% expenditures). OOP payments have more than doubled in volume between 2015 and 2018, from only US$9.3 40 0.5% 0.2% 0.4% per capita to US$22.4 per capita in 2018. However, between 2017 and 2018, the share of OOP payments in total 20 0.2% current health spending decreased by roughly 15 percentage points, for the first time since 2012 coming second 0.1 50.5 0.2 58.9 0.4 80.2 2.5 139.2 0 0.0% after external financing. Between 2012 in 2018, donor spending in CAR in the health sector has been increasing 2015 2016 2017 2018 tremendously from US$5.5 per capita in 2012 to US$27.6 per capita in 2018. Similarly, the share of donor spending Investment/Capital Health Expenditures Current Health Expenditures Total Health expenditures Share of Capital Health expenditures on Total Health Expenditures on total current health expenditure after falling by roughly 10 percentage points between 2015 and 2017 reached 51.4 percent of current health expenditure in CAR, becoming the largest source of financing of current health expenditure in CAR in 2018. Donor spending in 2018 of US$27.6 per capita represents roughly nine times the level Source: Author’s computations using the 2015-2018 NHA. of domestic government spending of US$3.4 per capita in CAR for the same year—far below the global target of US$86 per capita. Government is the third largest source of financing of the health sector in CAR after OOP The cost of health care per capita in CAR has increased by roughly threefold over the period 2015–18, from payments and external donors, and its share in current health expenditure decreased from 11 percent in 2016 US$19.02 (CFAF 11,247) in 2015 to US$54.6 (CFAF 30,368) in 2018. In addition, total health spending in the country to only 6.3 percent in 2018. Finally, other private funding (not OOP payments)—the fourth and lowest source has grown faster than GDP, with health spending estimated at 5.04 percent of the GDP in 2015 to 6.7 percent in of funding of the health sector—grew from only US$0.1 per capita in 2015 to US$0.4 per capita in 2018. External 2017 and 11.2 percent in 2018 (more than double 2015). donors and OOP payments by households as the two major sources of financing are a threat for the stability, sustainability, and predictability of health financing in CAR. TABLE 5.2. TREND IN TOTAL HEALTH EXPENDITURES IN CAR, 2015–18 Current health spending of donors per capita estimated at US$49.8 in international PPP is the highest level among relevant comparators, with the exception of Sierra Leone, Liberia, and Mozambique. Donor spending Relative growth 2015 2016 2017 2018 (2015–18)/Base 2015 per capita in CAR is also higher than all relevant regional groupings’ averages, namely SSA, FCV, and CEMAC when excluding Liberia and CAR. Likewise, the share of donor spending on total current health expenditures at 51.4 Total health expenditures (% GDP) 5.04 5.5 6.7 11.2 122% percent is higher than all its relevant comparators except for Mozambique, and higher than the regional averages Total health expenditures per capita in US$ (current) 19.02 21.9 30.1 54.6 187% for SSA, FCV, and CEMAC when excluding Liberia and CAR. Total health expenditures per capita in CFAF 11,247 13,016 17,536 30,368 170% Domestic general government health expenditure per capita in CAR is the lowest among relevant comparator countries and regional averages. Likewise, the share of domestic general government health expenditure on Source: Author’s computations using the WHO GED. total current health expenditure in CAR at 6.3 percent is one of the lowest among relevant comparator countries including regional averages, except Cameroon. Total health expenditures per capita are relatively low compared to relevant comparator countries in SSA and with data on capital health expenditures, except for Niger. This calls for an increased resource mobilization of the main OOP payments in nominal terms and as a share of current health expenditures are higher than the FCV average financing sources in CAR, mainly from the government. and only slightly higher than the LIC average with or without Liberia and CAR. The amount and share of other types of domestic private health spending are stubbornly low in CAR and are the lowest among all relevant comparators and regional averages, namely SSA, FCV, and CEMAC. TABLE 5.3. COMPARISON OF KEY TOTAL HEALTH EXPENDITURES INDICATORS IN CAR WITH OTHER RELEVANT COMPARATORS Capital health expenditures Total health Total health expenditures per capita Indicators (as of 2018) expenditures (% GDP) (in $US PPP international) External donors are the top funding sources of capital health expenditures in CAR. In 2015–16, all capital health expenditures were funded by external donors. In 2017–18, the government funded respectively 25 percent and Cameroon* 4.0 149.6 only 3 percent of capital spending in the health sector. From 2015 to 2018, no funding from domestic private CAR 11.2 98.8 donors was directed to capital health expenditures. Congo, Rep.* 2.2 129.9 Capital health expenditures in total and per capita in CAR are the lowest among relevant comparator countries and regional/subregional averages. External financing of capital health expenditures is the highest in CAR among Niger* 7.8 83.0 comparators, with only 3 percent of funding for capital health spending coming from the government and none Burkina Faso* 6.0 119.6 at all from domestic private sources. Such findings suggest that the government should find a way to allocate more resources in the health sector for capital expenditures, as well as a call for the private sector to bring more health Source: Author’s computations using the WHO GED. sector investment into CAR. Since 2015, capital health expenditures in CAR were mainly on infrastructure, followed 108 Note: * Countries with data on both current and capital health expenditures available in the WHO GED. 109 by medical equipment and transport (mostly reported in 2018). Investments on ICT equipment were only done in External donors funded 83 percent of CAR’s current health expenditures pertaining to governance, health 2018, representing only 1.1 percent of total capital spending on health (see figure A3.1 in Appendix A3). A thorough systems, and financing administration expenses, the highest share among its comparator countries, with only analysis by funding sources of capital health expenditures suggests that most health sector investments in 2018 19.7 percent funded by the government itself. This highlights the strong dependence of the government of CAR were by external donors, namely the Apostolic Nuncio116 (68.1 percent) and GAVI117 (24.5 percent). Such investments on external financing, a threat to the sustainability and predictability of the country’s heath system and financing. were spent on construction of residential buildings and acquisition of machinery and equipment. Similar to its comparators, current health expenditures on medical goods are mainly funded (at 100 percent) by domestic private sources, including OOP payments from households and other domestic private sources. By the end of 2020, more than one third of external financing for CAR’s social sectors (37 percent) was directed to health, making it the second largest external financing spending category after SP. In addition, there was a Only 3.3 percent of outpatient curative care and 0.5 percent of preventing care are funded by the government threefold increase of external financing devoted to the health sector between 2017 and 2018, representing 52 in CAR, the lowest among its comparator countries. The main financing sources for outpatient curative care are percent of total health spending in 2018. Box A3.2 in Appendix A3 provides a thorough description of the major domestic private actors (82 percent) including OOP payments from households. External donors are the major bilateral and multilateral donors involved in the health sector. source of financing for preventive care at an estimated at 99.5 percent, the highest among comparator countries. 5.4.1.3. BREAKDOWN OF TOTAL (CURRENT) HEALTH EXPENDITURES BY CATEGORIES Categorization by type of diseases Infectious and parasitic diseases118 are the top causes of current health expenditures in CAR. Between 2015 and Categorization by primary health care and health care functions 2018, current expenditures on infectious and parasitic diseases increased by more than twofold and their share on current health expenditures has fluctuated between 68 and 73 percent. Malaria alone, ranking fifth in the CAR had the highest share (93 percent) of primary health care expenses in current health expenditures in 2015– country’s Global Burden of Diseases (GBD) when considering DALYs, explains more than 30 percent of current 18, as compared to all relevant benchmark countries. External donors funded 53.5 percent of primary health care health expenditures (30.8 percent in 2016 and 35.4 percent in 2018). Surprisingly, tuberculosis ranked third, expenses; the government only funded 3.25 percent, the lowest compared to its relevant benchmark countries. represents less than 0.3 percent of current health expenditures between 2016 and 2018. The level and share of Following Mozambique, which funded 77.9 percent of its primary health care expenditures through donors, CAR current health expenditure dedicated to HIV/AIDS and other sexually transmitted diseases (STDs) also fell between came second with donors as the top financing source of primary health care. 2016 and 2018, from 18 percent in 2016 to only 6 percent in 2018, which is low considering the sixth place ranking of HIV/AIDS and STDs in the country’s most recent disease profile. FIGURE 5.10. SHARE OF PRIMARY HEALTH CARE ON CURRENT HEALTH EXPENDITURES AND FUNDING SOURCES, 2015–18 TABLE 5.4. LEVEL AND SHARE OF CURRENT EXPENDITURES ON INFECTIOUS AND PARASITIC DISEASES 100 other STDs, in CFAF millions CFAF millions CFAF millions CFAF millions CFAF millions Tuberculosis, HIV/AIDS and infections, in and parasitic vaccination, Diarrhea, in diseases, in respiratory Other non- 90 Malaria, in Neglected infectious avoidable classified Diseases diseases through millions millions 92.6 tropical in CFAF in CFAF 80 Acute 83.9 82 70 77.9 77.7 75.3 72.5 60 67.7 2015 3,833.73 663.62 17,267.77 1,200 2,700 150.73 6,009.48 5,200 65.6 50 56.8 53.6 7.6% 1.3% 34.2% 2.4% 5.3% 0.3% 11.9% 10.3% 40 48 42.1 41.8 40.5 30 2016 10,684.46 132.32 18,122.15 1,500.0 3,400.0 100.00 7,900.00 900.0 34.2 31 30.3 20 18% 0.2% 30.8% 2.5% 5.8% 0.2% 13.4% 1.5% 24.1 23.5 22.7 21.4 18.5 10 18.2 17.7 12.9 16.3 15.7 3.3 12 0 2017 8,138.28 185.47 26,574.57 2,200.00 4,900.00 100.00 11,600.00 1500 CAR Congo Ethiopia Guinea Kenya Liberia Mali Mozambique Niger BFaso Primary Health care (% of Current Health Expenditures) External donors % Primary health care 10% 0.2% 33.1% 2.7% 6.1% 0.1% 14.5% 1.9% Domestic General Government Health Expenditure % Primary health care 2018 8,658.19 319.31 49,302.47 4,100.00 8,900.00 200.00 18,500.00 5000 6% 0.2% 35.4% 3% 6% 0% 13% 4% Source: Authors’ computations using the 2015-2018 NHA. Source: Author computations using the WHO GED. Note: The percentage in italic represents the share on current health expenditures. Curative care received 53.2 percent of current health expenditures, out of which 5.5 percent was for inpatient care and up to 47.7 percent for outpatient care. Only 1 percent of current health expenditures were devoted to Diarrheal diseases, despite ranking first in the disease profile, represented less than 3 percent of current health medical goods as compared to 44 percent in Guinea, 26 percent in the Republic of Congo, or 29 percent in Niger. expenditures in 2018. The nominal amount devoted to diarrheal diseases increased by more than threefold Similar to most countries in SSA, only a very low share of current health expenditures was on ancillary services. between 2015 and 2018, but much more needs to be done. Similarly, only 6 percent of current health expenditures Among its relevant comparator countries, CAR had one of the highest shares (37.4 percent) of preventive care on were attributed to acute respiratory infections (ARI) in 2018, despite their fourth-place ranking in the DALY’s current health expenditures; and CAR spent only 8.1 percent of current health expenditures on governance and GBD. The government should undertake genuine reforms to increase the allocation of sufficient funding to ARI health systems, the lowest after Mali. and diarrhea. 116  See http://www.nuntiususa.org/. 118  These are malaria, HIV and other STDs, tuberculosis, neglected tropical diseases (NTDs), and other unclassified parasitic and infectious 110 117  See https://www.gavi.org/. diseases. 111 Over the 2015–18 period, more than 90 percent of current expenditures on infectious and parasitic diseases Categorization by age (under five years old versus more than five years old) were funded by external donors and domestic private payments sources (primarily household OOP payments). In 2018, only 6 percent of current health expenditures on infectious and parasitic diseases were financed by the Current health expenditure for children under five years as a share of total current health expenditure government. Likewise, more than 90 percent of current health expenditures related to malaria were funded by increased in 2016–18 by 10 percentage points, from 36 percent in 2016 to 46 percent in 2018. Current health external donors and domestic private sources, mainly OOP payments. Between 2015 and 2017, 54–68 percent of expenditures on children under five roughly tripled in 2018 as compared to 2016, hence following the same trend current health expenditures on malaria were financed by OOP payments and in 2018, only 4.8 percent of those of total current health expenditures in 2018 and representing 2.4 times the amount in 2016. The biggest increase expenditures were funded by the government compared to 51 percent funded by external donors alone. in the amount of health expenditures dedicated to children under five between 2016 and 2018 is from external donors followed, by domestic private health expenditures for children under five, which also doubled over the Despite challenges in getting access to family planning and contraception methods, CAR’s fertility rate ranks same period. However, government health expenditures for children under five only increased by 44 percent from among the top in SSA at an estimated 6.4 children per woman. Only 0.3 to 1 percent of current health expenditures 2016 to 2018—the lowest source of financing for under-five health expenditures between 2015 and 2018 (see were devoted to contraceptive management and family planning practice between 2015 and 2018 from the latest figure A3.7 in Appendix A3). National Health Accounts Data. However, we noticed a substantial continued increase of health expenditures devoted to contraceptive management from only CFAF 128 million in 2015 to CFAF 1,046 million in 2018, a sign that there is The top source of funding for health expenditures for children under five in CAR is domestic private health increased attention directed to contraceptive management and family planning, although much more still needs to expenditure, namely OOP payments of households. Still, the share the total current health expenditure for be done. Likewise, despite neonatal disorders ranking second in the DALYs in 2019, only 3–5 percent of current health children under five decreased by about 16 percentage points, from 60 percent in 2016 to 44 percent in 2018. The expenditures between 2015 and 2018 were devoted to maternal conditions, even though the committed amount second major source of funding was external donors, and their share in the total current health expenditure for rose almost six-fold over the same period. Injuries, despite ranking seventh in the CAR’s most recent disease profile children under five increased by 22 percentage points in 2016–18, from 27 percent in 2016 to 49 percent in 2018, (right after malaria and HIV/ AIDS), had no expenditures reported between 2015 and 2018. Over the same period, only outperforming domestic private sources (including OOP payments). The third source of funding for under-five 5–7 percent of total current health expenditures was allocated to nutritional deficiencies, despite the high stunting health expenditures come from the government, although its share decreased by half in 2016–18, from 14 percent rate in CAR. Finally, 5–7 percent of total current health expenditures between 2015 and 2018 were directed to NCDs, of the total current health expenditure for children under five in 2016 to only 7 percent in 2018. which mainly rank 10th and 11th in the country’s disease profile; this is a more than threefold increase in the nominal Over the same period, health expenditures for children under five as a share of GDP substantially increased value of NCDs expenditures, from CFAF 2,605.39 million in 2015 to CFAF 8,260 million in 2018. from 2 percent in 2016 to roughly 5 percent of GDP in 2018. However, under-five health expenditures as a share of general government expenditures slightly decreased from 2.4 percent in 2016 to 2 percent in 2018. Categorization by regions and gender The latter finding aligns with what was highlighted above on the decreasing share of under-five current health expenditures in government expenditures. We gather information on countries with a relatively similar level of Health expenditures are unequally allocated across regions, with Bangui and its suburbs receiving substantially stunting prevalence and current health expenditure per capita to compare CAR with other countries on their level more per capita than the health districts. Between 2015 and 2018, Bangui and its suburbs (region 7), which have of commitment to health outcomes for children under five through health spending. the lowest under-five mortality rate in the country, receive the highest budget per capita, four times the budget per capita received by region 4 (which has the highest under-five mortality rate in the country).119 Overall, region Among countries with data available on health expenditures for children under five, and with a relatively 7 (including Bangui and its suburbs) absorbed between 42 and 55.3 percent of current health expenditures, similar level of stunting and current health expenditure per capita, CAR has the highest level of spending on despite having the best level of access to health services and better health outcomes than the other six regions. children under five. The latest 2018 data show spending levels of US$44.5 per capita in CAR, which is even above In 2018, region 4 with the highest under-five mortality rate in 2018–19 only received 8 percent of current health expenditures of countries with a higher level of stunting such as Niger. CAR also fares better when considering expenditures, whereas region 7 (Bangui and its suburbs) received the highest share (almost half of the total expenditure for children under five as a share of GDP, which is established at 5 percent and higher than 3.9 percent budget—45 percent). in Niger. Under-five expenditure as a share of total current health expenditures (46 percent) is also higher than most comparable countries except for Niger, which also has a level of stunting roughly 8 percentage points higher than in CAR. Categorization by gender However, domestic government health expenditures per capita devoted to children under five remain low in There is a positive gender bias in the allocation of current health expenditures in CAR, with the highest share CAR, at only US$2.9 per capita in international PPP, the lowest of all relevant comparators (Mali, Benin, and going to women (representing 50.4 percent of the total population) and increasing from 65.5 percent in 2015 to Guinea).120. External donors’ health expenditures per capita dedicated to children under five are highest in CAR 67.1 percent in 2018. This is equivalent to a nominal increase in volume from CFAF 33.1 billion in 2015 to CFAF 93.4 (US$22 per capita international PPP), as compared to relevant comparators. This confirms our finding above, billion in 2018. This gender gap in current health expenditures between men and women has roughly tripled since suggesting that development partners have recently been the major financing sources for under-five health 2015 from a difference of CFAF 15.70 billion in 2015 (in favor of women) to a difference of CFAF 47.60 billion in 2018. related expenditures, outperforming domestic private modes of financing including OOP. In 2018, current health expenditures devoted to women were more than twice the amount dedicated to men. Despite the increasing volume of current health expenditures dedicated to men (from CFAF 17.4 billion in 2015 to CFAF 45.8 billion in 2018), the share of current health expenditures devoted to men in CAR has been decreasing, Categorization of total (current) health expenditures by financial schemes from 34.5 percent in 2015 to 32.9 percent in 2018. Compulsory financing arrangements (CFA) are all run through the government; compulsory health insurance This positive distribution of health resources toward women reflects the several social and health challenges women (CHI), made up of social health insurance (SHI) and compulsory private health insurance, have been absent in are facing in CAR as compared to men. Women’s challenges include a high maternal mortality ratio, low access to CAR since 2012 as potential financial schemes. Voluntary financing arrangements (VFA) are the main type of reproductive health services, and gender-based violence. Another need is increased women’s economic empowerment financing scheme in CAR, standing consistently at more than 70 percent of current health expenditures since 2012. for adolescent girls, which will be addressed under the new and upcoming Human Capital Project in CAR. This a far bigger share than CFA schemes, which were established at only 13.4 percent in 2018 and consistently have been below 30 percent since 2012. 119  Region 7 (under-five mortality rate 59.55 per 1,000 live births) receives CFAF 68,512 per capita while region 4 (under-five mortality rate 122.57 112 per 1,000 live births) receives CFAF 16,111.1 per capita. 120  Even if those countries tend to have a lower share of stunting as compared to CAR. 113 Among VFA, OOP payments have consistently been the major source of financing (consistently above 40 percent Domestic general Domestic general government Domestic government health since 2012) as compared to other forms of voluntary health care payments. Unlike other countries with a similar Indicators government health health expenditure per capita spending (% general government level of socioeconomic development, there is no other unspecified financial scheme in CAR except for CFA, solely (as of 2018*) expenditure (% of GDP) (US$) in PPP spending) (priority to health) (%) provided by the government, and VFA funded primarily by households OOP payments. Since 2018 and for the very first time, voluntary health care payments have outperformed OOP payments by roughly 3 percentage points, Burkina Faso 2.4 47.5 8.8 with the highest increase of roughly 10 percentage points recorded between 2016 and 2017. Over the exact same Sudan 1.0 66.9 6.8 period, government financing arrangements also have had their biggest drop from 25.98 percent in 2016 to only 15.58 percent in 2016. Source: Author computation using the 2018 WHO GED. *Latest year in the current WHO GED. 5.4.2. Government health expenditures 5.5.2.2 BUDGET ALLOCATION AND EXECUTION IN THE HEALTH SECTOR 5.4.2.1 OVERVIEW OF GOVERNMENT SPENDING IN THE HEALTH SECTOR The government budget for the health sector—encompassing the budget of the Ministry of Health, health-related Government health expenditures are still low in CAR, standing at 4.2 percent of total general government spending in other ministries, and donor-funded subcontracts—stood at CFAF 20.6 billion in 2020. This was the expenditures. The government’s share of total health expenditures in CAR is also low and consistently has been highest level of health budgeting for the past 8 years, roughly equivalent to 10 percent of the total government below 12 percent since 2015. From 2015 to 2018, domestic general government health expenditure per capita budget. Because of the COVID-19 vaccine response, the total executed budget for the health sector has roughly rose at a slower pace (100 percent rise) than the equivalent increase for total current health expenditure (159 doubled from CFAF 10.3 billion in 2019 to CFAF 20.6 billion in 2020, the largest recorded increase for the past eight percent rise). years. However, the total executed government budget from 2019 to 2020 only increased by 30 percent and GDP in current U.S. dollars remained almost constant. Health spending as a share of GDP has been stubbornly low Government health expenditures as a share of general government spending are one of the lowest levels in since 2012, with the highest value reached in 2020 at 1.5 percent. The WHO notes that countries with public health SSA after Cameroon, the Republic of Congo, and Guinea. Domestic government expenditures at 0.69 percent of spending at less than 4–5 percent of GDP find it difficult to approach universal health coverage. Likewise, the total GDP in 2018 are also one of the lowest levels in the region. Likewise, government spending per capita in PPP is the executed health budget as a share of the total executed government budget has been historically lower than 10 lowest among CAR’s relevant comparators. Finally, government spending per capita in PPP (6.1 $ PPP) is the lowest percent since 2012; it reached its highest level in 2020 thanks to increased domestic revenue mobilization in the among CAR’s relevant comparators. health sector to respond to the COVID-19 pandemic. However, this share remains low in comparison to the Abuja Target recommending 15 percent of the budget allocated to health (see table A3.12 in Appendix A3). TABLE 5.5. GOVERNMENT HEALTH EXPENDITURES, CAR AND RELEVANT COMPARATORS Between 2015 and 2018, salaries paid by the government and purchases of goods and services together represented more than 90 percent of total government health expenditures in CAR. Over the same period, government health Domestic general Domestic general government Domestic government health investments remained stubbornly low at less than 4 percent of the total government executed budget for the Indicators government health health expenditure per capita spending (% general government (as of 2018*) expenditure (% of GDP) (US$) in PPP spending) (priority to health) (%) health sector. However, in 2019–20, investments in the health sector substantially increased in nominal terms from CFAF 0.82 billion in 2019 to CFAF 5.3 billion in 2020, reaching up to 26 percent of the executed government Burundi 1.9 16.2 8.5 health expenditure in 2020. The latter could be attributed to the COVID-19 pandemic. There was also a drop in salaries as a share of government health expenditures from 68 percent in 2016 to only 14 percent in 2020. Cameroon 0.2 8.0 1.1 CAR 0.69 6.1 4.2 Chad 0.7 13.4 5.2 Box 5.1. The Wage bill of the Ministry of Health in CAR Congo, Rep. 0.8 46.1 3.5 Among the 1971 health workers in the payroll in 2020, only 46.63% (919 in absolute numbers) are frontline health workers and up to 42.4% are administrative health workers. The latter are in majority:  i) major a Ethiopia 0.8 15.6 4.8 la formation sanitaire ii) agent de bureau; iii) assistant d’assainissement iv) chef de service v) directeur Guinea 0.6 18.0 4.1 vi) garcon/fille de salle vii) surveillant general des etablissement. Those “administrative” health workers represent 46% of the total wage bill of the health sector in 2020 which is quite high. In addition, 10% of Kenya 2.2 75.5 8.5 health workers enrolled in the payroll are either awaiting to be deployed or in professional traineeship (“en stages”). A Medical doctor working as a public servant is getting paid on average FCFA 322,079.6 Sierra Leone 1.6 25.0 7.2 as a monthly wage (~USD 463) in 2020. The gross salary of a medical doctor in CAR is lower than what Liberia 1.7 3,180.7121 5.2 university professors are getting. An “Assistant” professor in CAR gets paid 409,962.6 CFA Franc on average per month; a “Maître assistant” gets 518,190.9 CFA Franc on average per month; a “Maître de conférence” Mali 1.1 25.4 5.4 gets 761,836.3 CFA Franc per month and a university professor an average of 886,021.8 CFA Franc per month. The total level of the Ministry of Health’s wage bill is 3499 million FCFA (USD 6 million). A back Mozambique 1.7 24.9 5.6 of the envelope calculation, that assumes a policy where the 35 percent of workers (worth FCFA 91.706 Niger 2.4 25.9 8.4 million in monthly salaries) that are outside of Bangui get a 25% bump in their salary, would lead to FCFA 22.926 million additional a month and FCFA 275.120 million a year. 121  Such a high value is attributed to the $ PPP exchange rate which has been the lowest in Liberia in 2018 with 1 international dollar equal to only 0.5 Liberian dollars and with a US$ to Liberian dollars exchange rate equivalent to 144.0 implying that the US Current international dollars 114 in Liberia should be multiplied by 278.32 to get the PPP International $ amount equivalent 115 FIGURE 5.11. OVERALL BUDGET EXECUTION RATE IN THE HEATH SECTOR, 2015–20 The low budget execution rate in the health sector reflects continued weaknesses in the budgeting process and inefficiencies in the expenditure health chain. Budget implementation in the health sector is severely constrained by the low level of domestic resources and compounded by the long delay in starting budget execution, usually 50.00 90% taking place only later in the year. Some potential drivers of the low budget execution rate in the health sector 45.00 77% 80% 71% are the lack of coordination and harmonization between planning and budgeting; difficulties in purchasing goods Budget exciution rate (in %) 40.00 70% Amount in CFAF billions 63% 66% and services due to the inadequate capacity in procurement procedures; and the reluctance of private suppliers 35.00 60% to participate in the procurement of goods and services in the health sector due to unpaid government arrears. 30.00 43% 50% 40% 50% 25.00 42% 32% 43% 40% Addressing those weaknesses by establishing a coordinated national health supply chain system which is 20.00 38% effective, sustainable, and transparent will be critical to improve the budget execution rate and ensure that 30% 15.00 basic health services are effectively delivered to the populations most in need. Another potential source of 10.00 23% 20% inefficiencies of government health expenditures could potentially come from the unequal allocation across 5.00 10% diseases and conditions, against the country’s priority and needs in terms of diseases and health conditions. 14.39 5.45 21.44 4.91 25.26 8.05 19.60 8.20 25.42 10.25 47.5 20.6 0.00 0% 2015 2016 2017 2018 2019 2020 Year Allocated Executed BER health BER Overall 5.5.2.3 ALLOCATION OF GOVERNMENT HEALTH EXPENDITURES BY TYPE OF DISEASES Source: Author computations using the 2015-2020 Budget data from the Ministry of Finance. There are allocative inefficiencies of government health spending across diseases and conditions, with only 0.2 percent of government health expenditures dedicated to TB, despite the disease ranking third in the most recent country’s disease profile. By comparison, malaria receives 27.3 percent of government health expenditures Budget execution rates in the health sector have consistently been lower than 50 percent since 2015 and below but ranks only fifth in the country’s GBD in CAR. No government funding from the health sector was directed to the total government budget execution rate. The gap between allocated and executed spending has also been injuries, despite ranking seventh in the country’s GBD right after malaria and HIV/AIDS. Similarly, only 2.3 percent widening since 2018. of government expenditures were devoted to HIV/AIDS, despite ranking sixth in the GBD. The budget execution rate122 for government health expenditures on investment has been less than 3 percent from 2015 to 2018, the lowest among all categories of health expenditures. However, we denote an increase from TABLE 5.6. GOVERNMENT ALLOCATION BY DISEASES AND CONDITIONS IN 2018 3 percent in 2018 to 20 percent in 2020 for the budget execution rate for investment health expenditures. This 17 percentage points increase reflects the government’s commitment to foster higher levels of investment in the Government expenditures on diseases/ Rank in the most recent health sector, still at it lowest. From 2015, transfers and subsidies but also goods and services were the two main conditions as share of domestic general country’s disease burden category of health expenditures with the highest budget execution rates. The budget execution rate for goods Type of diseases and conditions government expenditure on health (in %) profile (top causes of deaths) and services has been improving substantially since 2016 from 28 percent in 2016 to 98 percent in 2020. I. Infectious and parasitic diseases 65.0 HIV/AIDS and sexually transmitted diseases (STDs) 2.3 6 FIGURE 5.12. GOVERNMENT BUDGET EXECUTION RATE IN THE HEALTH SECTOR BY CATEGORIES OF EXPENDITURES, 2015–20 Tuberculosis (TB) 0.2 3 Malaria 27.3 5 100% Neglected tropical diseases (NTDs) 0.0 (Not among the top 11) Budget execution rate (in %) 90% 98% 93% 80% 88% 87% Other Infectious and parasitic diseases 35.1 (Not explicitly on the top 11) 84% 84% 81% 70% 60% 69% II. Reproductive health 15.3 50% 53% 52% 52% 40% 50% Maternal conditions 3.2 14 42% 43% 40% 30% 38% 31% 20% 28% Contraceptive management (family planning) 1.2 (Not among the top 11) 8% 20% 0.2% 10% 2% 3% 0% 0% Other reproductive health (Not among the top 11) 2015 2016 2017 2018 2019 2020 11.0 Year Good and Services Transfers and Subsidies Investment Salaries III. Nutritional deficiencies 0.8 (Not explicitly on the top 11) IV. Noncommunicable diseases (NCDs) 17.5 10 and 11 Source: Author computations using the 2015-2020 Budget data from the Ministry of Finance. V. Injuries 0.0 7 VI. Other unspecified diseases/conditions 1.3 (Not among the top 11) 122  The budget execution rate reported here is likely to have been underestimated given that only expenditures on domestically funded Source: Author’s computations using the WHO GED. resources have been reported as executed expenditures in the official budget data released; unlike allocated expenditures also including donor- 116 funded subcontracts. The PFM section of this PER provides a thorough analysis of the budget execution rate for each social sectors. 117 The trend and share of medical evacuations also reveal major inefficiencies of current health expenditures. FIGURE 5.13. HEALTH FINANCIAL INPUTS COMPARED TO HEALTH OUTCOMES, CAR AND Medical evaluation represented 2.4% and 2.1% of Total Current health Expenditures in 2016 and 2017 in CAR; higher RELEVANT COMPARATORS IN 2019/2020 than the share of current health expenditures allocated to Ancillary care as well as retailers and other providers of medical goods. The distribution of total current health expenditures by service providers from 2015 to 2018 in FCFA reveals that Medical evacuation was 1.15 billions CFA Franc on average over the 2015-2018 period with a peak 140 of 1.72 billion CFA Franc reached in 2017. There was a sharp increase of medical evacuation between 2015 and 2017 from 0 billions CFA Franc in 2015 to 1.43 and 1.72 billions CFA Franc in 2016 and 2017 respectively, which is somehow Chad Niger Under Five years old mortality Rate (Per 1000 live births) 120 Sierra Leone worrying for the health system. (See Table A.3.20 in the Annex). CAR When considering the breakdown of total government health expenditures by service providers, we observe Mali 100 a similar but an even bleaker picture with medical evacuation reaching 13.8% of Government Current health Burkina Faso expenditures in CAR in 2017 and an average of 10.2% over the 2016-2018 period. Most importantly, It should be DRC noted that over the 2016-2018 period, the government of CAR has funded more medical evacuations than its Cameroon Benin 80 Mozambique primary healthcare system (Health centers) with the total amount allocated for medical evacuations representing more than twice the amount allocated to ambulatory health services. More worryingly, in 2017 and 2018; Liberia medical evacuations represented more than twice (roughly 4 times in 2017) of total government current health Burundi 60 expenditures for preventive health care services. (See Table A.3.21 in the Annex). Sudan Congo, Rep. Overall, analysis of government spending in CAR suggests the existence of several sources and drivers of 40 Ethiopia inefficiencies. From a macro-level perspective, we could notice that a subset of relevant CAR comparator countries (Democratic Republic of Congo, Liberia, Cameroon, Benin, Ethiopia) achieve a lower mortality rate for children under five with lower health expenditures as a share of general government expenditures. Hence, even if slightly 20 reducing or keeping steady health expenditures, CAR should be able to achieve better health outcomes (including a lower under-five mortality rate). 0 0 2 4 6 8 10 12 Domestic General Government Spending on health (as a share % of General Government Spending) 140 Niger 120 Chad Sierra Leone Under Five years old mortality Rate (per 1000 live births) CAR Mali 100 Benin Burkina Faso DRC Liberia 80 Cameroon Mozambique Burundi Sudan 60 Congo, Rep. Ethiopia 40 20 0 0 5 10 15 20 25 30 Domestic General Government Spending on health per capita (in USD) Source: Author’s computations using the WHO GED. 118 119 Box 5.2. Infant mortality and domestic government expenditure on children under financial resources. We estimate concentration indices123 and plot concentration curves (in Appendix A3) to assess five years in Sub-Saharan Africa: the nexus the level of inequality in health outcomes and access to basic health services in CAR. Over the past few years in SSA, there has been a strong push toward increasing domestic public finance Regardless of place of residence (rural versus urban or region 7 versus the other 6 regions) or the level of for improving children’s health outcomes (PF4C) with a specific focus on children under the age of five. education of the mother, there is a significant concentration of stunting among children from less wealthy This is especially relevant in CAR where the level of stunting and mortality rate of children under five households. Likewise, there is a significant concentration of access to vitamin A and vaccines for TB, PT, and PC are among the highest on the continent. However, little is still known on the implications for domestic among children from better off households. Given that medical treatments are mainly funded by OOP payments public expenditure for improving children’s health outcomes. Between 2016 and 2018, government health from households, there is also a predictable and significant concentration of access to medicines among children expenditures for children under five as a share of general government expenditures in CAR decreased by 0.18 percentage points from 2.21 percent in 2016 to 2.03 percent in 2018. In 2018, CAR had one of the from better-off households. highest rates (84.46 per 1,000 live births) of infant mortality ratio (defined as the probability of a child dying before his first birthday). We combine the latest data from the WHO GED with data from WDI to assess the relationship between the priority given by government to health outcomes for children under TABLE 5.7. CONCENTRATION INDEXES AMONG KEY HEALTH OUTCOMES VARIABLES FOR five and the level of infant mortality in SSA. In total, 19 countries in SSA in 2018 had data on levels of under- CHILDREN UNDER FIVE five spending and infant mortality rates. We find a negative relationship between under-five spending as a share of government expenditures and the infant mortality ratio. Using a robust standard errors ordinary Concentration Index value least square regression, we find that holding everything else constant, a percentage point increase on the share of government under-five spending over total general government expenditures lead to a 6.56 Urban Health Region Other Region 7 vs Child Health Concentration Vs Rural 7 (Bangui + health other regions points decrease in infant mortality, a point estimate statistically significant at a 10 percent threshold. Variables Index valuea Urban Rural differencesb suburbs) regions differences Prevalence of -0.13*** -0.17*** -0.02 -0.15*** -0.062*** -0.078*** 0.016 FIGURE B4.1.1. INFANT MORTALITY AND DOMESTIC GOVERNMENT EXPENDITURE ON stuntingc CHILDREN UNDER FIVE IN SELECTED SUB-SAHARAN AFRICA COUNTRIES Prevalence of -0.016 0.010 -0.02 0.03 0.015 -0.015 0.03 diarrhea Access to Vitamin A 0.23*** 0.15*** 0.12*** 0.03 0.055** 0.18*** -0.12*** Access to a TB 0.21*** 0.07** 0.14*** -0.07 0.00 0.19*** -0.19*** Vaccine Access to a PT 0.19*** 0.148*** 0.092** 0.056 -0.01 0.2*** -0.2*** Vaccine Access to a PC 0.19*** 0.16*** 0.085** 0.075 0.018 0.15*** -0.13** Vaccine Access to medicine 0.09*** 0.033 0.087** -0.055 -0.036 0.083*** -0.12*** for any disease Source: Author computation using the 2018 MICS data. Note: a. The star indicates the level of statistical significance at a 95 percent confidence interval (legend: * p<.05; ** p<.01; *** p<.001). b. The statistical difference is computed under the large sample assumptions. c. After cleaning up the WHO Height for Age Z-core by making sure it remains within the -6SD and 6SD interval, we define stunting as the probability of HAZ <-2 Standard Deviation (SD). Source: Author’s computations using data from the WHO GED and the World Bank WDI. There is a significant concentration of stunting among the least wealthy both in Bangui and other the other health regions. Point estimates suggest that the degree of inequality is greatest in the six regions outside Bangui.124 The significant concentration in access to vitamin A, vaccines, and medicines among the better-off households happens predominantly in the six health regions outside of Bangui, with point estimates suggesting a higher 5.5. EQUITY IN ACCESS TO HEALTH SERVICES AND FINANCIAL degree of inequality within those regions. There is also a significant concentration in access to all types of vaccines PROTECTION for children under five among better-off households in both rural and urban locations.125 5.5.1. Equity There are large subnational disparities in health outcomes and access to basic health services in CAR. The above 123  We use the Erreygers concentration index best suited for binary outcomes variables and the wealth quintile index as a proxy for socioeconomic status. The concentration index takes a negative value when the health variable is concentrated among the disadvantaged or less wealthy and sections have already highlighted: (i) the important variation of health outcomes and access to basic health a positive value when the health variable is concentrated among the most advantaged or better-off households. A concentration index and services across socioeconomic groups in favor of those in the richest quintile, and (ii) the uneven and inequitable related concentration curve helps in quantifying the degree of income-related inequality in a specific health variable. distribution of health resources across regions with people having the worse health outcomes receiving fewer 124  Both statistical tests based on either the large sample or the equal variance assumptions fail to reject the null hypothesis that the concentration index is the same in region 7 versus the other six health regions. 125  Both statistical tests based on either the large sample or the equal variance assumptions fail to reject the null hypothesis that the 120 concentration index is the same in rural and urban locations. 121 Among pregnant women of a childbearing age (15–49), there is a significant concentration of access to antenatal Although OOP health payments from households accounted for around 60 percent of health expenditures back care for pregnant women among better-off households both in urban and rural locations. However, there is only in 2008, only 6.7 percent and 1.2 percent of households were allocating respectively more than 10 and 25 percent a significant concentration of access to antenatal care for pregnant women among the better-off households in of their entire income to health-related expenses. A thorough comparison of CAR with relevant benchmark the other 6 health regions except Bangui.126 There is also a significant concentration of access to antenatal care for countries in SSA using data from 2008128 suggests that the incidence of catastrophic health expenditures in CAR pregnant women among the better-off households, both among more educated and less educated women; the was already higher than in countries with a similar share of either household OOP payments or OOP payments point estimates suggest that the degree of inequality is greater among less-educated mothers.127 We also found per capita (in US $ PPP). In 2007, Tanzania had 55.8 percent of current health expenditures covered by household a significant concentration of ownership of any form of health insurance or a vaccination card among the better- OOP payments. At the same time, Tanzania only had 2.2 percent and 0.3 percent of households with health off households in both rural and urban locations, and also among less and more educated women who were expenditures at more than 10 percent and 25 percent of their income, respectively, as compared to 6.7 percent and better off. On access to a social insurance and to a vaccination card, the point estimates suggest that the degree 1.2 percent in CAR. Niger, with similar OOP indicators to CAR, had 3.7 percent and 0.6 percent of households with of inequality is greater in urban areas. Regarding the ownership of a vaccination card, the degree of inequality catastrophic health expenditures at more than 10 percent and 25 percent, respectively, of their income. Burkina is greater for other health regions outside region 7, whereas for the ownership of a social health insurance, the Faso, another relevant benchmark for CAR, was estimated to have 3.5 percent and 0.6 percent of households with degree of inequality is greater in health region 7. However, the statistical difference between the two group of health expenditures at more than 10 percent and 25 percent of their income, respectively. regions is not significant. TABLE 5.9. COMPARISON OF THE INCIDENCE OF CATASTROPHIC AND IMPOVERISHING HEALTH TABLE 5.8. CONCENTRATION INDEX ON VARIOUS MATERNAL HEALTH OUTCOMES BY LOCATION EXPENDITURES IN CAR AND LEVEL OF EDUCATION OF THE MOTHER estimate catastrophic Impoverishing health expenditures at 25% expenditures at 1.90 Concentration Index value household’s income household’s income catastrophic health catastrophic health catastrophic health OOP payments per of household total Household budget (most recent year) (most recent year) (year estimate of (year estimate of (year estimate of in US$ PPP year capita US$ PPP OOP payments GDP per capita at 10% of total Maternal Health Region Region 7 vs expenditures expenditure) expenditure) expenditure) Catastrophic Catastrophic health Concentration Urban vs rural 7 (Bangui + Other health other regions survey year variables index value Urban Rural differences suburbs) regions differences US$ PPP Access to 0.232*** 0.13*** 0.13*** −0.002 −0.0033 0.195*** −0.198*** Country antenatal care Angola 12.4% 4.5% 2.0% 2008 21.65 44.8 6221.4 Ownership of 0.014*** 0.0183*** 0.0058** 0.0124** 0.0128*** 0.0075*** 0.005 a social health insurance CAR 6.7% 1.2% 1.1% 2008 57.95 20.4 873.5 Ownership of 0.274*** 0.19*** 0.14*** 0.048 0.047 0.22*** −0.176*** Côte d’Ivoire 15.2% 3.6% 3.0% 2008 59.39 95.8 2553.8 a vaccination card Burkina Faso 3.5% 0.6% 1.2% 2009 31.44 24.2 1348.0 Advanced level of education Low level of education Mali 4.4% 0.7% 2.0% 2009 61.81 57.5 1779.4 (primary 2 & secondary school) (no education or primary 1 Differences Sudan 18.4% 3.3% 3.0% 2009 52.48 131.8 3927.6 Access to antenatal care 0.034** 0.185*** −0.151*** Uganda 19.6% 3.9% 4.1% 2009 37.25 58.5 1614.0 Ownership of a social health insurance 0.023*** 0.0042*** 0.018*** Cabo Verde 2.0% 0.0% 0.1% 2007 75.05 80.0 2691.9 Ownership of a vaccination card 0.185*** 0.191*** −0.006 Guinea 4.3% 0.2% 1.7% 2007 22.92 52.2 5437.7 Source: Author computation using the 2018 MICS data. a. The statistical difference is computed under the large sample assumptions. Niger 3.7% 0.6% 1.2% 2007 71.56 38.3 1558.6 Tanzania 2.2% 0.3% 0.9% 2007 55.28 30.6 726.7 5.5.2. Financial protection Source: Author’s computation using the WHO GED and the World Bank HEFP database. From 2000 to 2018, OOP payments from households accounted for more than 40 percent of total current health expenditures, thereby putting the population at a significant risk of catastrophic and impoverishment health The relatively higher incidence of catastrophic health expenditures does not necessarily push CAR households expenditures. From 2000 to 2018, the share of OOP payments from households have been consistently above below the poverty line of US$1.90 PPP, as this only 1.1 percent of households had this impoverishing level of the average in SSA (see figure A3.9 in Appendix A3). There is no recent household budget survey to get a recent health expenditures in 2008, a level below the estimates in relevant benchmark countries except for Tanzania. estimate of the incidence of catastrophic and impoverishing health expenditures in CAR. Under the large sample assumption, the index is greater in health regions outside of Bangui. 126  128  We include SSA countries with household budget survey done in 2007 and 2009 given that Angola, Côte d’Ivoire and Mozambique are The T-test under the large sample assumption reject the null hypothesis that the index is the same among low and advanced educated 127  the only countries with household budget survey conducted in 2008. Finally, we removed countries with share of households’ out of pocket 122 mothers. payments on total current health expenditure at less than 20 percent to keep a good comparison sample with CAR. 123 In 2007–09 in the SSA region, the only countries with similar shares of OOP payments were Sudan,129 Uganda, Côte and December 2020, despite the relatively small number of positive COVID-19 cases131 and related deaths, the d’Ivoire, and Angola. OOP spending per capita in CAR more than doubled after 2008 with an average growth rate of government was able to allocate CFAF 16.2 billion (equivalent to US$30.042 million) for risk prevention, mainly in the 7.3 percent, roughly 28 times higher than the average annual growth rate of the GDP per capita of 0.3 percent over form of transfers and subsidies, out of which CFAF 11.7 billion were executed. We follow the projection’s framework the same period. Hence, we expect the projected level of catastrophic expenditures at 10 percent and 25 percent of Kurowski, Evans, Tandon et al. (2021) to assess the macroeconomic implications of the COVID-19 pandemic for to be equivalent to almost twice the incidence back in 2008 meaning 13.4 percent and 2.4 percent of households health financing by making various assumptions regarding the trend of government health expenditures per allocating respectively more than 10 percent and 25 percent of their income to health expenditures. capita for the next five years (2021–16). The following equation defines the mathematical relationship between general health expenditure (GHE) per capita, the ratio of general health expenditures to general government expenditures (GGE), public expenditure as a share of GDP, and the GDP per capita: TABLE 5.10. TREND OF OOP PAYMENTS PER CAPITA IN CAR OOP payment per capita GDP per capita OOP payments (% of current (in US$) (in US$) health expenditure) 2008 11.11 475.8 57.9 Government health Health share Public expenditure expenditure per of government GDP per capita 2009 10.83 474.7 48.3 as a share of GDP capita expenditure 2010 10.77 487.9 60.4 2011 11.65 551.0 58.1 We compare the projected GHE per capita for the 2021–26 period with the SSA average under the five following main scenarios: 2012 11.23 565.8 54.7 Scenario 1: Status quo: This scenario makes the assumption that governments protect the share of GHE in GGE, 2013 8.07 380.2 44.8 which remains similar to the 2016–19132 average. To get the forecasts of GHE per capita, we use equation (1) above by multiplying the 2016–19 average priority to health (estimated at 5.16 percent in CAR) with the 2020–26 IMF’s133 2014 10.44 423.9 50.2 projected government general expenditures for GDP and GDP per capita. We find that between 2020 and 2021, 2015 9.26 377.3 48.8 GHE per capita is expected to rise by US$1.10 from US$5.03 to US$6.13 and then drop between 2021 and 2022 to US$5.50 per capita and continuously increase till 2026 at US$7.03 per capita (12.12 $ PPP), roughly five times lower 2016 12.08 401.9 55.2 than the projected average GHE per capita in SSA in 2026 estimated at 64.53 $ PPP. Under this scenario the 2020– 26 yearly average growth rate of the GHE per capita in PPP is equivalent to 2.7 percent (see table A3.13 in Appendix 2017 16.91 449.8 56.4 A3), higher than the growth rate of the GHE per capita in SSA under the same scenario. Assuming total health 2018 22.36 488.2 41.7 expenditures remain the same as in 2018 (meaning at 54 $ per capita) from 2020 to 2026, and external financing maintains its highest level reached at 28 $ PPP per capita from 2020 to 2026 with other private payment also Relative change (base year 2008) 101% 3% -28% remaining constant at 0.37 $ PPP in 2021, OOP payments are expected to fall from US$20.72 in 2019 to US$18.73 in 2026. Average growth rate 7.3% 0.3% -3.2% Source: Author’s computation using the WHO GED. FIGURE 5.14. PROJECTED TREND IN OOP PAYMENTS PER CAPITA UNDER SCENARIO 1 Challenges in access to health services are disproportionately concentrated among the poorest and most vulnerable 60.0 21.00 households and only 1 percent of women and men owned social insurance in 2018 (MICS 2019). Therefore, the 50.0 20.50 share of households experiencing catastrophic health expenditures at either 10 percent or 25 percent is expected Expenditures in $ 20.07 OOP payments in $ 20.72 19.62 19.75 19.35 18.94 18.73 to have increased between 2008 and 2018 but could start decreasing post-2019. This is thanks to the free health 20.26 20.00 40.0 care policy introduced by the government in February 2019 and targeting children under five, pregnant women, 19.50 30.0 and victims of GBV. However, we lack sufficient data to be sure. 19.00 20.0 18.50 10.0 5.6. IMPLICATIONS OF COVID-19 FOR HEALTH FINANCING IN CAR 18.00 0.0 17.50 2019 2020 2021 2022 2023 2024 2025 2026 In the short run, the COVID-19 pandemic has had a pronounced impact on public finance worldwide, pushing Year governments and external130 donors to dedicate increasing resources to pandemic response. Between July External Otherprivate GHE OOP OOP Source: Author projections using data from the 2021 WEO and the WHO GED. 129  However, in Sudan for instance where the share of out-of-pocket payments from households in 2011 was at a relatively similar level (52.5 percent); up to 18.4 percent (respectively 3.3 percent) of households were allocating more than 10 percent (respectively 25 percent) of their entire income to health. However, the amount of out-of-pocket payments per capita in Sudan is more than 6 times the one in CAR and their 131  There were 4,971 COVID-19 confirmed cases and 63 COVID-19 deaths by December 2020 (UNICEF, 2020). GDP per capita in $ PPP is not comparable. 132  Even though the latest data available in the WHO GED is 2018, we have the budget from the MoF for CAR allowing us to get an estimate of 130  In April 2020, the EU, the World Bank, the IMF, the AfDB, and the AFD were planning to mobilize CFAF 83.63 billion to respond to the COVID-19 the 2019 share of GHE on GGE, which was estimated at 6.2 percent. 124 pandemic. 133  The IMF projection is the latest one from the World Economic Outlook done in April 2021. 125 Scenario 2: Pro-health: GHE per capita continues to grow at the average yearly rate observed 10 years before the 5.7. OVERVIEW OF RESULTS BASED FINANCING IN THE HEALTH SECTOR COVID 19 pandemic (2009–19), estimated at 4.40 percent in CAR and 6.75 percent in SSA. We find that between 2020 and 2021, GHE per capita is expected to rise by only US$0.24 from US$5.26 to US$5.5 and then continuously IN CAR increase till 2026 at US$6.8 per capita, 8.29 $ PPP, roughly 42 times lower than the projected average GHE per capita in SSA in 2026 estimated at 349.4 $ PPP134 (see table A3.14 in Appendix A3). By making the same assumptions Results-based financing (RBF) was introduced in CAR in 2012 under a component of the National Health System about the level of total health expenditures, external financing, and other private payments, OOP payments are Support Project through a supply-side performance-based financing (PBF) in five health regions outside Bangui, expected to fall linearly from US$20.72 in 2019 to US$18.95 in 2026 (see figure A3.10 in Appendix A3). namely regions 2, 3, 4, 5, and 6. However, the PBF was already existing in health regions 1, 2, and 6 since 2009. In 2016, the PBF coverage was extended under the World Bank-funded Health System Support Project reaching the Scenario 3: Procyclical: GHE per capita responds to GDP per capita with the same cross-country elasticity as equivalent of 40 percent of the population in regions 2, 3, 4, 5, and 6. It allows a performance purchasing agency during the 2000–18 period. We estimate the linear relationship between GHE per capita and GDP per capita using (PPA) to contract health posts, health centers, and district and regional hospitals to deliver an agreed package of a regression in CAR and SSA, where we find a negative significant relationship.135 We find that between 2020 reproductive, maternal, and child health (RMCH) services. Facilities are incentivized based on (i) the volume of and 2026, GHE per capita is expected to continuously fall from US$3.18 to US$2.28 in 2020 equivalent to 3.12 $ RMCH services delivered, and (ii) the technical quality of these services. PPP, roughly 71 times lower than the projected average GHE per capita in SSA in 2026 estimated at 223.4 $ PPP136 (see Table A3.15 in Appendix A3). By making the same assumptions about the level of total health expenditures, Figure 5.17 below shows an increase positive increase in the quality scores volume of key RMCH services in CAR external financing, and other private payments, OOP payments are expected to rise linearly from US$20.72 in 2019 from 2017. to US$23.48 in 2026 (figure 5.15). FIGURE 5.17. EVOLUTION OF KEY OUTCOMES IN PBF DISTRICTS FROM Q1 2017 TO Q3 2020 FIGURE 5.15. PROJECTED TREND IN OOPS PER CAPITA UNDER SCENARIO 1 300,000 60.0 250,000 50.0 OOPs payments in $ Expenditures in $ 40.0 200,000 Number 30.0 150,000 20.0 100,000 10.0 50,000 0.0 2019 2020 2021 2022 2023 2024 2025 2026 0 External Otherprivate GHE OOP OOPs 2017Q1 2017Q2 2017Q3 2017Q4 2018Q1 2018Q2 2018Q3 2018Q4 2019Q1 2019Q2 2019Q3 2019Q4 2020Q1 2020Q2 2020Q3 Year-quarter Source: Authors’ projections using data from the 2021 WEO and the WHO GED. Pentavalent 3 Home Visit Antenatal Consultations 1-4 External consultations children 0-59 months Source: CAR PBF database, Ministry of Health. FIGURE 5.16. SUMMARY OF THREE PROJECTIONS OF GHE PER CAPITA UNDER DIFFERENT SCENARIO An analysis of the relationship between the increase in RMCH services and quality scores of health facilities pre-COVID-19 suggests a positive correlation. RBF funds are held by the PPA and released quarterly upon the 8.00 verification of results by an External Evaluation Agency in charge of checking both the quantity and the quality of 7.00 6.00 services delivered. In May 2019, around 50 percent of the population was covered with the PBF. The government 5.00 then decided to roll out the reforms to 100 percent of the population by the end of 2020 with additional funding 4.00 from the World Bank and the European Union. 3.00 Overall, the PBF intends to promote transparency and good governance within the heath sector by improving 2.00 1.00 the efficiency and equity of quality health care services. The PBF focuses on health programs that address 0.00 diseases and risk factors with a significant contribution on the most recent country’s GBD profile, namely: (i) HIV, 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 2026 tuberculosis, malaria; (ii) vaccination; (iii) reproductive health; and (iv) malnutrition. In 2012, an impact evaluation Scenario1 Scenario2 Scenario3 using a cluster-randomized trial to assess the efficacy and effectiveness of the RBF program in CAR was launched and a baseline survey took place between February and December 2012 in health regions 2, 3, 4, and 6. In total, Source: Authors’ projections using data from the 2021 WEO and the WHO GED. there were approximately 242 clusters made of 97 health centers and 145 health posts, and no more than 20 households were randomly selected in catchment areas around these clusters. 134  This high PPP average is more driven up by Liberia with its outstanding PPP value. 135  In CAR, we find that over the 2000–18 period, a unit increase in the GDP per capita is significantly associated with a US$0.0037 decrease on GHE per capita (in current US$) while in SSA over the same period, a dollar increase in the GDP per capita is associated with a US$0.0609 increase in the GHE per capita. 126 136  This high PPP average is more driven up by Liberia with its outstanding PPP value. 127 The endline data collection is yet to be completed and the impact evaluation is expected to focus on 29 core 5.8. RECOMMENDATIONS indicators disentangled into coverage of (i) maternal and child health services (10 indicators137); and (ii) quality of care138 at the health facility level including health posts, health centers, and hospitals (19 indicators). Over RECOMMENDATIONS FOR THE TIME the past few years, several empirical impact evaluations based on rigorous quantitative methodology have been GOVERNMENT FRAME SPECIFIC ACTIONS OBJECTIVES/GOALS MINISTRIES conducted settings similar to CAR, mainly in FCV countries such as Burundi where the impact of PBF programs MAJOR/PRIMARY POLICY RECOMMENDATIONS was found positive. In Burundi, Bonfrer et al. (2013) found that the PBF program increased the probability of I.a. Compensate the uneven Short to • Pursue the action plan of the • Enhance the delivery • Ministry of Health women delivering in a health care facility by 21 percentage points and accessing antenatal care by 7 percentage distribution of health workers medium national health community of essential health • Ministry of Finance points. The use of modern family planning services and the overall health facility quality score also improved by between health region 7 (Bangui) term policy by recruiting 1 voluntary services and improve • Ministry of Civil and the remaining six health CHW who will be able to cover health outcomes in Service 5 and 46 percentage points, respectively, as the result of the PBF. Strong evidence was found for heterogeneity regions by: 20 households equivalent to regions most in need. • Ministry of Higher of impacts across socioeconomic groups. Likewise, Basinga et al. (2011) evaluated the impacts of PBF in Rwanda roughly 100 people (assuming This will also improve Education i) recruiting more community using a randomized controlled trial and found that it had its largest effect on institutional deliveries, causing an 5 individuals per households). equity of access to • health workers (CHWs) in regions This implies a need of 10,838 health services which increase of 23%. In Burkina Faso, Lohmann et al. (2018) used a quasi-experimental methodology with a nested with poorer health outcomes and CHWs in region 3, 6,952 is a key intermediate lower CHWs per capita, namely experimental component and found positive impacts on the utilization of maternal care services and family regions 3 and 1 CHWs in region 4, and 6,380 objective toward CHWs in region 6. With 554 reaching universal planning among the poorest 20 percent of the population. ii) making other health regions CHWs in region 3,558 CHWs health coverage in outside of Bangui attractive to in region 4, and 555 CHWs CAR. An Iterative Beneficiary Monitoring (IBM) survey conducted on July 12–14, 2018 under the scope of the previous new graduate health workers in region 6 as per the latest by granting a special premium data available of CHWs per Health System Strengthening Support Project (PASS) suggests that 97 percent of health facility managers to those willing to relocate to regions (2017 HeRAMS survey), claimed that the PBF had very positive effects on their respective health facilities. However, the following safe health regions with a higher the government will need to aspects likely to undermine the performance of their facilities were highlighted: (i) late payment of salaries, health facilities ratio per 10,000 recruit 1,143 CHWs, 711 CHWs, inhabitants as compared to and 648 CHWs139 in regions 4, leading to the demotivation of some staff; (ii) lack of awareness among the population of the mechanisms for Bangui (regions 3, 4, and 6) or 5, and 6 respectively for each identifying vulnerable groups who should receive free health care; and (iii) the lack of a ‘quality improvement to experienced health workers year till 2030, the due date of willing to relocate. the national health community bonus’ to encourage achievements. The IBM also highlights the need to strengthen staff capacity regarding the policy. iii) Invest in decentralized technical aspects of the PBF, including a refresher training to update technical knowledge on the PBF, including training of nurses, midwives and • Create a set of incentives financial and drugs management. Additional capacity-building trainings were also requested to strengthen the community health workers, as (indemnités)/bonus scheme to individuals who are already living make health regions outside quality of services for treatment of tuberculosis and HIV/AIDS, family planning, and the management of HIV of Bangui attractive for new in remote and rural areas are transmission from mother to child and laboratory screening. Most of these requests have been addressed under more likely to stay there upon graduate health workers upon completion of their medical the PBF component of the Health System Strengthening Support Project (SENI) and others will be addressed graduation. degree or experienced health under the ongoing SENI Plus project. I.b. Train CHWs, nurses and workers willing to relocate obstetric care health workers on to lower their willingness to family planning and reproductive remain in the capital city. health services, Integrated Management of Childhood Illness (IMCI), and other health care practices to tackle neonatal disorders, the second causes of DALYs in the recent country’s disease profile. II. Reallocate a larger share Short to • Improve the delivery • Ministry of Finance of current health spending to medium of essential health • Ministry of Health understaffed health regions with term services and enhance sufficient health facilities and health outcomes by the most pressing health needs promoting equity and in particular health regions 3, fairness in access to 4, and 6 in lieu of region 7 and health care. increase the share of government • Improve long-term spending on health outcomes for human capital children under five outcomes likely to yield higher economic returns in the long run. 137  Maternal and Child health Coverage indicators include: The proportion of children under 1 who have received all of their vaccines; Contraceptive method use rate (modern methods);Unmet need for family planning; Children under 5 who slept under a mosquito net the night before the survey; Children under 3 who received vitamin A; Delivery by qualified personnel; Women who attended one or more antenatal visits during their most recent pregnancy; Children ages 11 to 59 months who participated in growth monitoring during the past months; Women who received tetanus toxoid vaccination in the most recent pregnancy; and Women who received postnatal care in the most recent pregnancy. 138  Quality of care indicators at the health facility level cover various aspects including availability of basic antenatal care equipment, clinical 139  These are upper bound estimates of the needs in CHWs as the actual number of CHWs per health region is likely to have increased since the 128 equipment, essential drugs, etc. latest data collection in 2017. 129 RECOMMENDATIONS FOR THE TIME RECOMMENDATIONS FOR TIME GOVERNMENT FRAME SPECIFIC ACTIONS OBJECTIVES/GOALS MINISTRIES EXTERNAL DONORS FRAME SPECIFIC ACTIONS OBJECTIVE GOALS EXTERNAL PARTNERS III. Reallocate a greater share of Short to • Improve the allocative • Ministry of Finance II.a. Support the CHWs Short to • Improve the delivery • Main bilateral , government health spending medium efficiency in the • Ministry of Health recruitment policy across regions medium of essential health multilateral and to the fight against diseases term health sector by outside of Bangui (with a focus term services and enhance humanitarian donors playing an important role on the redirecting resources on regions 3, 4 and 6) by sending health outcomes by (GAVI, EU, World country’s Global Burden of Disease to fighting diseases volunteers in the field to enhance enhancing equity and Bank, France, The (GBD), in particular diarrhea, with the highest the CHWs’ training curriculum on efficiency Netherlands, UNICEF, neonatal disorders, tuberculosis, DALYs and their major various health practices. • Improve long term MSF, etc.) and acute respiratory infections underlying causes human capital II.b. Allocate a greater share (ARI), including major risk factors such as children’s outcomes likely to of external financing to driving the most deaths and malnutrition/stunting. yield higher economic understaffed health regions with disability in the country, namely returns in the long run sufficient health facilities and malnutrition, WASH, and air the most pressing health needs pollution. mainly health regions 3, 4, and 6 IV. Allocate a greater share of Medium • Increase investments on basic • Improve the • Ministry of Finance in lieu of region 7 (Bangui and its public spending to capital/ term medical supplies and on the predictability of public • Ministry of Health suburbs) and increase the level investment spending, hence expansion, rehabilitation of health spending • Ministry of public of external financing on children shifting away from current health facilities’ buildings. by substantially works under five. type of spending and adopt • Equip regions with the lowest decreasing the heavy III. Allocate a greater share of Medium • Equip regions with the lowest • Improve health • Main bilateral, accompanying measures to number of beds per 10,000 reliance of the health external financing to investment term number of beds per 10,000 outcomes and access multilateral and improve the involvement of the inhabitants namely regions 4, sector on external in health capital formation inhabitants namely regions 4, to health services in humanitarian donors private sector in the provision of 5, and 6. loans and grants, and support the government 5, and 6. regions most in need. (GAVI, EU, World health services. • Expand/rehabilitate and to the hence changing in creating more space for the • Expand/rehabilitate and to • Lower CAR’s level of Bank, France, The extent possible construct more the revenue-raising private sector in the provision the extent possible construct OOP payments, which Netherlands, UNICEF, central hospitals outside of paradigm in the of health services, especially in more central hospitals outside is one of the highest in MSF, etc.) Bangui. country. regions outside of Bangui with low of Bangui and bring in more the CEMAC subregion • Increase the level of current • Lower the level of OOP health outcomes and poor health advanced health technology to and in SSA. health expenditures on payments, one of the services delivery. close the urban/rural areas gap collective services (prevention highest in the CEMAC in access to health services and public health services) by subregion. lowering expenses on curative health services. SECONDARY LEVEL POLICY RECOMMENDATIONS REFERENCES CAPACITY BUILDING Basinga, P., Gertler, P.J., Binagwaho, A. Soucat, A.L., Sturdy, J., and Vermeersch, C.M. 2011. “Effect on maternal I. Build the local capacity of Short to • Organize regular training • Enhance the quality • Ministry of Health staff at the Ministry of Health medium sessions with the WHO and availability of • Ministry of Finance and child health services in Rwanda of payment to primary health-care providers for performance: an impact to improve the reporting and term statistical team, the World National Health • National Statistical evaluation”. The Lancet 377 (9775): 1421-1428. construction of National Health Bank, and the CAR national Accounts data Office Accounts and foster data statistical office on the and the degree of Bonfrer, I., Soeters, R., van de Poel, E., Basenya, O., Longin, G., van de Looij, F., & van Doorslaer, E. 2013. “The effects harmonization with the RMET construction and reporting harmonization with of performance-based financing on the use and quality of health care in Burundi: an impact evaluation.” The and WHO Global Expenditure of National Health Accounts datasets coming Lancet 381 (2): S19. Database. The recently launched (NHA). from the investment Health Management Information case, the budget Kurowski, C., Evans, D.B., Tandon, A., Eozenou, P.H-V., Schmidt, M., Irwin, A., Cain, J.S., Pambudi, E.S., and Postolovska, System (HMIS) could serve as department/ Ministry a data houseware/hub for this of Finance and the I. 2021. “From Double Shock to Double Recovery - Implications and Options for Health Financing In The Time Of initiative. RMET. Covid-19.” Washington, DC: World Bank. II. Build the capacity of local Short to • Organize regular training • Enhance the budget • Ministry of health Lohmann, J., Muula, A. S., Houlfort, N., and De Allegri, M. 2018. “How does performance-based financing affect agents at the Ministry of Health medium sessions on donors’ execution rate in the • Ministry of Finance health workers’ intrinsic motivation? A Self-Determination Theory-based mixed-methods study in Malawi.”  Social and at the health facility level on term procurement procedures. heath sector. • External donors donor’s procurement procedures. Science & Medicine 208: 1-8. Ministry of Health and Population. 2019. “Politique Nationale de la Santé Communautaire RCA 2020-2030.” UNICEF. 2020. “Central African Republic; Coronavirus (COVID-19) Situation Report n°10.” https://www.unicef.org/ documents/car-covid-19-situation-report-november-december-2020 RECOMMENDATIONS FOR TIME EXTERNAL DONORS FRAME SPECIFIC ACTIONS OBJECTIVE GOALS EXTERNAL PARTNERS MAJOR/PRIMARY POLICY RECOMMENDATIONS I. Reallocate a greater share of Short to • Improve the allocative • Main bilateral , external financing to the fight medium efficiency in the health multilateral and against diseases playing an term sector by redirecting humanitarian donors important role on the country’s resources to fighting (GAVI, EU, World most recent Global Burden diseases with the Bank, France, The of Disease (GBD) in particular highest DALYs and Netherlands, UNICEF, diarrhea, neonatal disorders, major risk factors MSF, etc.) tuberculosis, and acute respiratory such as children’s infections (ARI), including the malnutrition leading major risk factors driving the to higher stunting most deaths and disability namely rates malnutrition, WASH, and air pollution. 130 131 CHAPTER 6. SOCIAL PROTECTION140 140  The The author of the social protection chapter is Frieda Vandeninden. Philippe Auffret and Paola Cerutti provided valuable contributions. 132 133 6.1. INTRODUCTION • Lack of teachers: The student-teacher ratio (STR) in 2018–19 for primary level was 91, significantly higher than the SSA average of 38 (Chapter 4 on Education). Social protection programs acting on the demand for The political context and the COVID-19 crisis represent an opportunity for boosting social protection (SP) in CAR. schooling must be paired with reinforcing the infrastructure and numbers of schools and teachers. The current pandemic crisis has exacerbated an already precarious situation, driving numerous households into • Low literacy: Only 30.3 percent of girls ages 15–19 are literate versus 43.1 percent for boys. poverty while further impacting the poor and increasing extreme poverty by 1 to 2 percent (World Bank 2020a). Adults: CAR has one of the lowest levels life expectancy (52.9 years in 2017) and adults depends mostly on The recent presidential elections (December 2020) brought another wave of violence. These crises present an subsistence agriculture. opportunity to build consensus and attract political support over the necessity to build a SP system in CAR and reinforce social safety nets (SSN). Delivering safety nets to the poor and those impacted by COVID-19 is also a • The low adult survival rate could be addressed by increasing access to preventive and curative health services. way to legitimize state intervention in a nonthreatening way to armed groups. A functioning SSN system would Next to reinforcing the health services offers (Chapter 5 on Health), social assistance programs, under the reinforce trust in institutions and at the same time rebuild the social contract between the government (central forms of fee-waivers for care, could reduce adult mortality, for which the main causes are conflict, HIV/AIDS, and local) and the population. malaria, malnutrition, and tuberculosis. • The poor often practice subsistence agriculture and do not earn adequate income (World Bank 2019, SCD). Building a national SP system is critical to reduce poverty and build human capital. The poverty, informal work, A ‘promotive’ feature to SP could better connect poor households to skill-enhancing and income-generating and unemployment rates in CAR remain high, threatening social stability and security in the country. CAR’s activities. Human Capital Index is among the lowest in the world, reducing youth opportunities and compromising future • Women face high inequality in terms of education and economic empowerment. Violence against women generations. About 70 percent of the population is living in poverty (World Bank 2020a). It is therefore essential and girls is particularly high, with 11,000 reported incident per year. Overall, CAF records one of the highest to improve SP (see box 6.1 for definition) and ensure it meets to needs of the current and future generations. In worldwide scores on the gender inequality index of 0.692 (159 over 162 countries) (World Bank 2020a). such a context, a SSN system that targets the most vulnerable households and generates human capital building • People with disabilities: People with disabilities are among the population groups most at risk of poverty is particularly needed. (World Bank 2020a). Support to this group in the form of social assistance or inclusion measures is needed. A SSN system is also a necessary complement to health and education policies, and is key to breaking the Elderly: Together with the disabled, the elderly is another group particularly at risk of poverty (World Bank 2020a). intergenerational transmission of poverty and vulnerabilities. As shown in Chapters 4 and 5, it is important to Old-age pension coverage is extremely low in CAR, focusing on public sector workers only. boost the supply of health and education services, but the latter should also go in pair with increasing the demand for such services. Social protection allows household to increase the demand for health and education services Internally displaced persons: Repetitive shocks and crises have led to high levels of displacement (695,000 in many ways: by relaxing household budget constraints (for example, through predictable cash transfers), by persons, World Bank 2020a), which adds another need for SP responses. These households are particularly at risk providing free or subsidized care (for example, fee waivers for childcare), through incentives and conditionalities of poverty, low living conditions, and poor health and nutrition. Humanitarian projects have supported IDPs, as (for example, school feeding programs, conditional cash transfers), or by directly distributing nutriments and well as the Return and Reintegration Support Project in CAR (PARET). food items to the vulnerable. Investing in people through SSNs directly contributes to building human capital. Evidence from African countries, including countries affected by fragility, conflict, and violence (FCV), shows that Social safety nets are the first line of defense to protect the poor and vulnerable in the FCV context. In FCV SSN programs have the potential to increase educational and health outcome (Beegle et al. 2018). countries, affected by recurrent crisis, mass displacement and suffering from low or collapsed service delivery and institutional capacities, SSNs consist mainly of humanitarian aid from different partners. Effectively tackling There is a large need for SP in CAR, at different levels across population groups and along the life cycle. The the challenges of FCV countries requires taking a long-term development approach and working in concert with poverty and human capital preliminary diagnosis (based on 2019 estimates, as the latest household survey was humanitarian actors.141 A SSN system should be allowed to pursue several objectives that are equally important to in 2008) calls for some SP responses, often going paired with addressing health and education supply barriers. the CAR context, including: (1) Equity—ensuring the poor and vulnerable reach a minimum level of consumption Human capital gaps are enormous in terms of children health and education. As detailed in Chapter 1, the country and cover their basic needs; (2) Resilience—build household resilience to shocks and prevent use of adverse coping records some of the lowest human capital indicators in the world. Addressing human capital gaps rests on strategies; and (3) Opportunities—foster opportunities by investing in human capital and productive activities different responses in terms of SP for each population group. (Beegle et al. 2018). Young children: This chapter presents an analysis of the current state of SP in CAR, depicting the type of programs currently in place, and their financing and management. It is structured as follows: • The high under-five mortality rate could be improved by programs that address food insecurity, and inform on feeding practices and hygiene. Such programs should go be paired with improved access to essential health Section 6.2 provides an overview of the SP sector. It first reviews the status of the national SP system, and shows the services (Chapter 5 on Health). recent development toward the adoption of a national strategy (section 6.2.1.). It then presents the different actors • The high maternal mortality ratio (829 deaths per 100,000 live births in 2017) calls for better access to involved in SP, focusing first on international partners (section 6.2.2). In a context with of a multitude of actors, antenatal and maternal care, for example by providing women incentives or reducing the cost of consultations coordination mechanisms are much needed. Section 6.2.3 depicts the recent development in this area. Section 6.2.4 through fee waivers. reviews the different national institutions and their respective functions according to the legislative framework. • The high stunted rate (41 percent of under 5), causing risk of cognitive and physical limitations, could be reduced by improving maternal and childcare practices and providing better nutrition. Section 6.3 provides an analysis of SP spending, focusing mainly on SSNs. The budget and executed expenditure • The low level of pre-primary school enrollment rate (9 percent, see Chapter 4 on Education) calls for a more of each SP-related ministry is presented in section 6.3.1. Budget allocations highlights the lack of funding and the comprehensive early childhood policy. low level of interventions. Overall SP spending, including both national and external funding, are presented in section 6.3.2, including (i) trends over time and across countries and in-depth analysis of each spending category; School age children: (ii) SSN programs financed using national funds; (iii) national SSN cash transfer programs LONDO and PACAD (financed by the World Bank); and (iv) spending on humanitarian and emergency assistance. Section 6.3.3 assess • The low school enrollment rate (particularly for lower and upper secondary, with 39 percent and 20 percent the adequacy of SSN programs, looking at (i) overall coverage trends and (ii) coverage gaps. The effectiveness and respectively in 2019), high out-school-rate (with 30 percent of children ages 6-11 being out-of-school) and low completion rates (particularly for girls, with only 34 percent for primary school versus 50.4 percent for boys) could be improved by providing incentives for schooling, such as school feeding programs (that also have the 134 potential to improve children nutrition). 141  Social protection: Protecting the poor and vulnerable during crises (worldbank.org) 135 the efficiency of SSN programs are then reviewed, focusing on (i) targeting of SSN, (ii) the program types, and (iii) TABLE 6.1. AVAILABILITY OF SSN PROGRAMS IN CAR, BY CATEGORY the fragmentation of the system (section 6.3.4). Sustainability issues are discussed in section 6.3.5. Program category Availability Section 6.4 offers a set of recommendations and an action plan, with immediate and medium-term actions. 1. Cash transfers Poverty alleviation programs PACAD Box 6.1. Social protection categories—definitions Family and child allowance (including orphan and vulnerable NA (only contributory benefits for orphans) Social protection systems help societies manage risks and volatility and protect households from poverty children benefits) and destitutions. They include a wide range of interventions and instruments that differ in nature and Housing/utility allowance benefits NA (only in the form of emergency support for IDPs) scope. Typically, SP systems can be classified under one of the three categories: Emergency support in cash (including support to refugees/ Cash under humanitarian and emergency projects 1. Social insurance (SI) returning migrants) Social insurance includes all programs that have a contributory nature, that is, beneficiaries are part of the financing mechanism. They pay an insurance premium or a percentage of their earnings to a mandatory Scholarships benefits Scholarships for higher education (nationally financed) insurance scheme. Individuals not contributing are not covered by social insurance interventions. The primary objective of SI is to help individuals and households coping with sudden changes in income 2. Food, in-kind, and near-cash transfers because of old-age, unemployment, sickness, and disability. Food stamps and vouchers NA (only in the form of emergency support) 2. Labor market (LM) programs LM programs are of two types: Food distribution programs NA (only in the form of emergency support) • Passive LM programs: their objective is to protect individuals against loss of income from unemployment; and School feeding/take-home School feeding (UNICEF and PAM) • Active LM programs: they help individuals acquire skills and connect them to labor markets. Nutritional programs (therapeutic, supplementary and people NA (only in the form of emergency support) Depending on their design they can be contributory or non-contributory (for example, unemployment living with HIV) insurance is contributory while a wage subsidy program targeting a group of vulnerable population is non-contributory). LM policies in place in CAR are mainly under the form of income-generating activities. Emergency support (including refugees/returning migrants) Vouchers and food distribution under humanitarian and emergency projects 3. Social assistance (SA) programs, also referred to as the social safety net (SSN) SA programs include non-contributory interventions, since beneficiaries are not part of the financing Targeted subsidies: Health benefits and reduced medical fees Three health targeting subsidies (free care for women victims for vulnerable groups of violence, subsidized treatment for HIV patient, and state mechanism. Their primary objective is to help households and individuals cope with poverty, vulnerabilities, contribution to subsidized vaccinations) and to reduce inequalities. SSN programs can take the form of (1) cash transfers; (2) food, in-kind, or near-cash transfer (such as vouchers); and (3) social care services (local institutions proving support to Targeted subsidies: Educational fee waivers NA vulnerable population). Targeted subsidies: Housing/utility NA More specifically, SSN interventions under each category typically include different program types, such as poverty alleviation cash transfers, scholarships, emergency support in cash, emergency support in- School supplies NA kind/near-cash, food distribution, and so forth (as detailed in box 6.2). Food for work (including food for training, food for assets etc. NA The category “emergency support” includes include all humanitarian projects. They can take the form of cash, food, or in-kind/near-cash support. 3. Social care services Institutions providing care and support to women, disabled, Counseling for HIV patients, and promotion and advocacy of Source: Definitions adapted from World Bank (2018). children, HIV patients, etc. maternal and child health Source: List of programs in CAR from several sources, see Appendix A2. Notes: NA=Not applicable (there is no SSN in place in CAR under these categories). Note that the bulk of the SSN in CAR is emergency support (from the humanitarian community), in the form of cash, food, or vouchers, as detailed in section 6.3.2. 6.2. OVERVIEW OF MANAGEMENT AND INSTITUTIONAL CONTEXT OF THE SOCIAL PROTECTION SECTOR The analysis in this section reveals that the management and institutional context of SP is characterized by (i) a lack of national SP strategy but increased interest in developing social safety nets; (ii) emerging coordination The SP system in CAR is mainly driven by the non-contributory pillar, as social insurance and labor market are mechanisms; (iii) the intervention of a plethora of international partners; and (iv) many national institutions limited. Given the high level of informality in the country, the scope of social insurance (SI) is mainly limited to involved in SP with low institutional memory. public workers only and will remain narrow until more workers join the formal labor market. Labor market (LM) policies are also crucial in boosting employability and increasing the labor force, but few LM interventions are implemented in CAR (mainly under the form of income-generating activities, see Appendix A2). The SSN system consists of different types of interventions, with emergency programs representing the largest portion. The list of SSN interventions is summarized in table 6.1. 136 137 6.2.1. An emerging national social protection strategy 6.2.2. Reliance on international partners and lack of coordination While there is no official national strategy, SP has recently become a priority for the country’s development. mechanisms In 2016, the government adopted its first State Consolidation Development Program (plan de Relèvement et la Social protection in CAR is only nascent, and relies mostly on the interventions from international partners. Consolidation de la Paix—RCPCA). The RCPCA’s second pillar “Renewing the social contract between the state and Armed conflicts and recurrent crises have harmed national institutions and created a gap in state representation the population” aims to restore and improve infrastructure, establish the necessary capacity to provide quality at the local level. The sector therefore mainly consists of donors from NGOs multilateral and bilateral partners social and administrative services, such as the provision of basic services. The plan recognizes that SP has the that finance and implement most interventions. Overall, the sector rests on short-term emergency responses potential to promote social cohesion, ensure food security and resilience, and increase access of the population from international partners (see section 6.3.2. for SSN spending composition). to basic services. The plan envisions developing administrative capacities, improve the institutional set up for SP, and targeting vulnerable populations. Many international partners are involved in SP in CAR. In 2020, more than 37 partners were financing SSN interventions, mainly emergency and humanitarian programs (representing overall about 75 percent of SSN Preliminary steps toward the adoption of a national SP strategy have been taken. In 2018, a steering committee spending, see section 6.3.2). Partners in 2020 included 18 international NGOs, 5 UN agencies, as well as bilateral for the actualization of the national SP strategy was created, under the presidency of the Primature, the Ministry donors (USAID, Germany, and France being the largest). The numbers as well as the mix of donors has changed for the Advancement Women’s and Children’s Affairs (Ministère de la Promotion de la Femme de la Famille et frequently over years and even by semester. In 2019 for instance, 26 partners were involved in SSN interventions, de la Protection de l’Enfant—MPFFPE); the Ministry of Labor, Jobs and Social Protection (Ministre du Travail, de with the three top bilateral donors being USAID, SIDA (Sweden), and Norway (OCHA 2020). The heavy reliance l’Emploi et de la Protection Sociale et de la Formation Professionnelle—MTEPSFP); and the Ministry of Finance and on numerous external actors jeopardizes the medium-term vision of SP. The country needs to move away from Budget. The committee also included members of the Ministry of Health, Ministry of Education, The Ministry of short-term interventions, often driven by political and financial constraints of the partners, and establish a long- Human Action and National Reconciliation (Ministère de l’Action Humanitaire et de la Réconciliation Nationale— term vision of how SP could address vulnerabilities, while building resilience and human capital. MAHRN), and the National Fund for Social Security (Caisse Nationale de Securité Sociale—CNSS). Committee members worked together on the elaboration of a draft strategy, but the committee has not been active since June There is no formal coordination mechanism for SSN programs but initiatives have recently emerged. The 2019. The drafting process revealed some different understandings of SP (Central African Republic Government multisectoral nature of the steering committee for the update of the SP strategy was a first step toward 2019). recognition of the need for coordination among the different national actors involved in SP activities. In 2018, an Inter-ministerial Unit for SSN Coordination (Cellule Interministérielle de Coordination des Filets Sociaux— A draft of the national SP strategy was elaborated in 2019, with a large focus on SSN. The draft strategy aims to CIFS) was created under the Prime Minister and the MAHRN. The initial objective of the inter-ministerial unit was bridge the gap between donor-driven emergency programs and long-term approaches to resilience. It is based on to strengthen coordination by setting up a national system for monitoring SSN programs and by developing a three pillars, under which SP options are envisioned: national beneficiaries’ registry. The unit is currently involved in the implementation of a cash transfer in Berberati. The activities related to the coordination of SSN programs have not yet started due to lack of resources and • Pillar 1: Promoting universal SP, by (1) offering a cash transfer or a child support (allocations familiales) to capacity (only three persons are involved in the CIFS, one from the MEPC, one from the MAHRN, and one from the every household that makes a request (the draft considers introducing conditionality such as vaccination or Ministry of Finance and Budget). school attendance to such transfers); (2) setting up a national school feeding program to provide free meals in all schools; and (3) promoting mutual health insurance. On the international partners’ side, a post-intervention reporting mechanism for humanitarian interventions • Pillar 2: Protection of vulnerable groups, by focusing on specific population groups (women in rural areas, has been recently established, and partners have further marked their engagement in extending such a persons with handicaps, children, and others). The draft also envisions developing a targeting strategy to mechanism to the overall SP sector. Since 2019, the UN Cash Working Group has collected information on SSN identify vulnerable groups. programs, including data on spending and coverage from donor-funded humanitarian and emergency programs. • Pillar 3: Reinforcement of the social insurance system, by modernizing the CNSS and extending social However, this collection does not entail any ex ante coordination mechanism, as it reports data post-interventions. insurance coverage, and insuring payments to current beneficiaries. In September 2020, UNICEF initiated a SP working group, with the objective of creating a forum that could help coordinate SP initiatives from both national and international actors. The working group should be co-led by a The draft strategy includes a more systemic vision of SP as well as promising interventions—but it has not yet national partner, which has not yet been identified given the political context. been adopted. The strategy needs to build consensus among the national actors involved in SP and set the stage for coordinated interventions, based on a common understanding of the needs of the populations. With 2020 Effective coordination is crucial given the numerous international actors involved in the sector. The SP sector being marked with the COVID-19 pandemic and a presidential election, the strategy has not yet been adopted by has a heavy reliance on international partners, both for financing and implementation of interventions, as detailed the government. below in section 6.2.3. In such a context, effective coordination mechanisms are most needed, and should ideally be led by national actors. The decision to expand SSNs and formalize a strategy must come from the dynamics of domestic politics. A clear vision of the demand for SP and a roadmap on how to address it is particularly needed when many external In the absence of a SP strategy and coordination mechanism, and with the involvement of numerous actors, partners are involved. Even in countries relying heavily on international partners for the financing of SP, the the risk of overlaps and duplications is high. The sector lacks identification and prioritization of the needs of decision to successfully expand SSNs has been made within a clear government strategy (Beegle et al. 2018). the population in terms of SP, as well as the key interventions that could best address SP needs. There is in fact no common vision and no leadership from national institutions. Instead, leadership is diffused across several A bottom-up approach to build the SSN system could insure its feasibility. Given the large numbers of actors institutions active in SP. There is no clear line ministry for SSN interventions, as detailed in section 6.2.3. and interventions (section 6.2.2) and the weak institutional capacity (section 6.2.3), the SSN strategy needs to be connected with what is actually in place in the country. This requires a bottom-up approach that reviews all current SP-related programs and then, based on what exists and what works (aka the ‘bottom’) elaborates a programmatic 6.2.3. National institutions involved in social protection umbrella (aka the ‘up’.]] The credibility of the strategy could in fact be increased by linking proposed interventions with what is currently implemented in the country. Such a stock-take exercise would be the first step toward The role of national institutions needs to be clarified as strong leadership is needed. There are several ministries building a coordination mechanism. and institutions involved in the SP system, leading to a lack of clarity on the respective responsibilities of each actor. The absence of a SP strategy creates a lack of systemic comprehension of how the different actors interact and on a lack of a common vision in the sector. 138 139 There are different ministries involved in SP interventions. MTEPSFP is responsible for Social Insurance and 6.3. PUBLIC EXPENDITURE ON SOCIAL PROTECTION Labor market programs. CNSS, created in 2006,142 is in charge of collecting social contributions and paying benefits to eligible beneficiaries, under the administration of the public treasury. Many institutions are involved in the This section reviews budget allocation and execution rate from the national institutions involved in the sector, provision of SSN programs. followed by a spending review of all interventions, including those financed externally. Then, the section proposes an assessment of overall expenditure in the sector in terms of coverage, effectiveness and efficiency, and There have been many changes in SSN institutions over the years. Over the period 2012–16, the Ministry of sustainability. Social Affairs, National Solidarity and Family (Ministère des Affaires Sociales, de la Solidarité Nationale et de la Famille—MASSNF) was in charge of interventions covering the poor and vulnerable. The 2015 elections led to overhauling many institutions and the creation of a new SSN-related ministry, called the Ministry of Social 6.3.1. Trends in budget allocations Affairs and National Reconciliation (Ministère des Affaires Sociales et de la Réconciliation Nationale—MASRN). The MASRN was shortly after reshuffled into two different entities created in 2017—the MAHRN and MPFFPE. Social safety net spending from the national budget is limited and represents only a small share of all SSN interventions in the country. Nationally financed SSN programs are included in the executed spending of In 2020, the MAHRN and MPFFPE have responsibilities directly related to SSN, including several directorates different ministries, as part of intervention expenditures (that is, only those interventions that are delivered as and units each responsible for a specific topic: a direct transfer to the population). Direct transfers represent a relatively small share of all SSN expenditure, as most of the SSN is financed by international partners. SSN spending, including both nationally and donor-funded • The MAHRN is responsible for the elaboration and implementation of programs and strategies in the field of interventions, are discussed in section 6.3.2. humanitarian action, national reconciliation, and fight against extreme poverty. It includes several directorates: (1) the directorate of humanitarian action, tasked with coordinating national and internationally financed Overall, budget allocations to ministries involved in SP are low. In many fragile and post-conflict countries, SP programs; (2) the directorate of SSN, in charge of the SSN strategy and implementation; and (3) the directorate spending is not a priority. Sectors that received the most attention are usually security related, while the ones of evaluation and statistics. The MAHRN is also in charge of the Inter-ministerial Unit for SSN Coordination that receive the least attention are public administration and SP (UNDP 2019). The CAR is no exception: only 2.6 (Cellule Interministérielle de Coordination des Filets Sociaux). percent of the total government budget is allocated to the MAHRN, 0.7 to the MPFFPE, and merely 0.1 percent • The MPFFPE is in charge of elaboration and implementation of programs against violence toward women and to the MTEPSFP (figure 6.1). The executed spending of the three SP-related ministries represented less than 1.5 children, protection of the handicapped and elderly persons, and care of HIV patients. It includes among other percent of total government actual expenditure in 2019. Execution rates are low for SP ministries at 27 percent for a directorate of social affairs, which provides social care activities (including counseling for HIV patients, and the MAHRN, 35 percent for the MPFFPE, and 11 percent for the MTEPSFP. By comparison, the executed spending promotion and advocacy of maternal and child health) (Central African Republic Government 2019). of the Ministry of National Defense was 15.6 percent of total government spending, the largest share among all ministries (followed by the MFB and the MPSE, with 7.25 and 8.05 percent respectively). Other ministries, whose core activities are not directly related to SP, are also involved in the implementation of some SSN programs, including: • The Ministry of Economy, Planning, and Cooperation (MEPC): While the MEPC has a large mandate, it is also in FIGURE 6.1. BUDGET AND EXECUTED SPENDING BY SP MINISTRIES AS SHARE OF TOTAL charge of one national SSN program—the labor-intensive public work LONDO (see Appendix A2.3 for program GOVERNMENT EXPENDITURE AND EXECUTION RATE, 2019 (%) review), funded by the World Bank. LONDO was the first national SSN program, starting in 2015 right after the end of the armed conflict. Given the recovery of most institutions at the time and the multi-dimensional 3.0 40 nature of the project (combining cash transfer and road maintenance), the MEPC was chosen as responsible 2.6 35 ministry. 2.5 • The Ministry of Primary and Secondary Education (MPSE): The MPSE manages school feeding interventions, 30 % of total spending Execution rate, % which are up to now financed by the UN World Food Program (Programme Alimentaire Mondial—PAM) and 2.0 25 UNICEF. 1.5 20 • The Ministry of Higher Education (MES): The MES is in charge of financing higher education scholarships. 1.1 15 1.0 There are potential overlaps in the attributions of SSN institutions. In the context of relatively new institutions 0.7 10 and in the absence of a national strategy for SP, the role of ministries and their associated directorates/units is 0.5 0.4 unclear. There is risk of duplication between institutions that navigate the same field. The respective role of each 0.1 5 0.0 institution should be weighed against its costs. Illustrating the potential high costs, the 2020 and 2021 budgets 0.0 0 MAHRN MPFFPE MTEPS (Loi des Finances 2021) indicate that several units under the MPFFPE and the MAHRN have budgets for office supplies only and no intervention expenditures. In % of Government Budget In % of total governement Executed Execution rate Institutional memories need to be built and leadership reinforced. In countries that have endured several and Source: Authors’ calculations based on 2019 executed budget (Ministry of Finance and Budget 2019). profound political crisis, it takes time to build new institutions and knowledge within them. With recent institutions, resources are usually first dedicated to setting up the machinery and little is left to plan the interventions, such as SSN programs. The economic classification of expenditures of the MPFFPE and the MAHRN shows in fact that SP-related ministries’ spending has historically been low in CAR, but has recently increased. Over the period most of their resources are dedicated to operating expenditures (dépenses de fonctionnement). The budget and 2012–18, executed spending of SP-related ministries represented less than 1 percent of total executed government executed spending of SP-related ministries reflects the low level of interventions (as detailed below in section spending, and less than 0.1 percent of GDP. The year 2019 is marked by a large increase in executed spending 6.3.3.1). from the MAHRN, MTEPSFP, and MPFFPE, reaching 1.5 percent of government expenditure and representing approximately 0.2 percent of GDP (figure 6.2). The COVID-19 pandemic in 2020 led to a decrease in executed spending to 0.15 percent of GDP, which is however higher than any other level pre-2019. 140 142  Law n° 06.034 of December 28, 2006 on the creation of the CNSS. 141 FIGURE 6.2. EXECUTED SPENDING BY SP MINISTRIES AS SHARE OF TOTAL GOVERNMENT FIGURE 6.4. EXECUTED AND BUDGET EXPENDITURE, BY TYPE OF EXPENDITURE, MPFFPE AND EXPENDITURE AND GDP, 2012–20 (%) MTEPSFP, 2019 1.60 0.20 MPFFPE MTEPS 1.40 0.18 % total government spending 0.16 1.20 0.14 Executed Compensation to 1.00 0.12 Executed employees % GDP 0.80 0.10 Operating 0.08 expenditures 0.60 0.06 Intervention 0.40 0.04 Budget Budget 0.20 0.02 Investment 0.00 0.00 2012 2013 2014 2015 2016 2017 2018 2019 2020 0 500 1000 1500 2000 0 200 400 MASSNF MAHRN MTEPS MPFFPE in % of GDP Source: Authors’ calculations based on 2012–19 executed budget (Ministry of Finance and Budget 2019). Source: Authors’ estimation based on 2019 budget. Note: GDP data from World Bank’s World Development Indicators (February 2021). Note: Data on executed compensations to employees (dépenses de personnel) are not available for both the MPFFPE and MTEPSFP. Budget allocations in SSN spending show a decreasing trend also for 2021, illustrating the difficulty of securing The good execution rate of intervention spending of the MAHRN is encouraging. This ministry has relatively sustainable funding for SSN programs given tight budget constraints. The budget allocations of the ministries large shares of executed spending on wage compensations and intervention spending. The level of operating involved in SSN started decreasing in 2020 and are expected to further decrease in 2021, as a potential consequence expenditure (dépense de fonctionement) is similar that of the MPFFPE. The execution rate of intervention of the COVID-19 pandemic. Therefore, consolidation of a budget for SSN programs is important to insure the expenditure of the MAHRN is close to 100 percent, with CFAF 1,146.7 million being executed over the budget of sector’s sustainability (figure 6.3). CFAF 1,170.6 million (figure 6.5). Intervention expenditures include transfer to NGOs, support to local committees (such as Commités locaux de paix), and several SSN interventions. The low execution rate of the MAHRN is mainly due to the gap between budgeted investment expenditure and actual investment expenditure. The latter FIGURE 6.3. BUDGET ALLOCATION OF NATIONALLY FINANCED SSN PROGRAMS, 2019–21 concerns installation, equipment, and renovation of offices, but also allocations to investment projects related to SP. The overall execution rate of the MAHRN deteriorated from 27 percent in 2019 to 16 percent in 2020, indicating persisting issues in the sector. 4000000 3500000 3000000 FIGURE 6.5. EXECUTED AND BUDGET EXPENDITURE, BY TYPE OF EXPENDITURE, MAHRN, 2019 2500000 (CFAF MILLION) FCFA 2000000 1500000 1000000 500000 Executed Compensation 0 to employees Budget 2019 Budget 2020 Budget 2021 Operating MPFFDE Social care services MSP Targeting subsidies: health MES Scholarship MAHRN In-Cash expenditures Intervention Source: Authors’ estimation based on Appendix A2.1. Budget Investment The fact that SP-related ministries are relatively new institutions is reflected by the composition of their 0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 expenditure. When setting up new institutions, there is an entry cost (usually under the form of investment cost) and the need to hire and pay civil servants (compensation to employees). The composition of each ministry budget and executed spending offers additional insights on the type of activities and their importance in each Source: Authors’ calculations based on 2019 budget. ministry (figure 6.4). For instance, the executed spending for the latter two ministries focuses only on operating expenditures (dépenses de fonctionnement, such as office supplies and energy bills), and investment expenditures (dépenses d’investissement, such as office furniture, cars, and construction of offices). 142 143 FIGURE 6.6. SI, LM, AND SSN SPENDING AS A 6.3.2. Overall social protection FIGURE 6.8. SSN SPENDING AS A SHARE OF GDP, CROSS-COUNTRY COMPARISON (%) SHARE OF GDP, 2019 (%) expenditure, nationally and externally funded 4.00 1.80 3.50 1.63 This subsection presents spending related to all 1.60 3.00 types of SP intervention, including those financed 2.50 1.40 by international partners. It includes spending on SI, 2.00 1.70 spending as % of GDP LM, and SSN programs. Expenditures of the first two 1.53 1.65 1.20 1.50 SP pillars are relatively small and our analysis focuses 1.50 1.00 0.90 mainly on the SSN sector. 1.00 0.80 0.50 0.60 0.00 6.3.2.1. COMPOSITION OF SOCIAL PROTECTION Burkina Faso 2016 Burundi 2015 Botswana 2019 South Africa 2016 Chad 2018 Sierra Leone 2011 Mozambique 2015 Low income countries Congo, Dem. Rep. 2016 Regional average Nicaragua 2013 Liberia 2016 Sudan 2016 Niger 2017 Guinea 2015 Rwanda 2016 Namibia 2018 Central African Republic 2019 0.40 EXPENDITURE 0.20 0.01 0.03 The main bulk of SP spending is in the form of SSN 0.00 LM programs Pensions SSN programs. Labor market programs have recently (public) emerged, under the forms of training and income- generating activities. Overall spending on the later Source: Authors’ calculations based on Appendix A2. remain small, reaching barely 0.01 percent of GDP in 2019 (figure 6.6). Expenditure on pensions (including Source: ASPIRE database (consulted February 2020) and World Bank (2018) for regional average. CAR 2019 is authors’ estimation based on old age, disability, and survivor) for the public sector Appendix A2. FIGURE 6.7. SSN SPENDING AS A SHARE are also relatively small (0.03 percent of GDP).143 In OF GDP, BY PROGRAM AND SOURCE OF turn, SSNs represent a larger 1.63 percent of GDP. FUNDING, 2019 (%) The share of nationally financed SSN has increased over time, reflecting growing government engagement with The SSN system is driven by external financing, SP. At the end of the political crisis in 2015, a stocktaking exercise of SSN interventions (recorded in the World Bank threatening the system’s sustainability. The share ASPIRE database) found that no SSN programs were nationally financed. Since then, the government has engaged of externally financed SSN programs was 76 percent directly in the provision and financing of SSN programs (0.39 percent of GDP, representing 24 percent of total 0.07 0.12 of GDP in 2019. Only 24 percent of SSN programs are SSN spending). However, the share of nationally funded SSN programs remains very low. Regionally, nationally funded SSN programs represent 55 percent of total spending, including externally funded programs (Beegle et % of GDP financed nationally, accounting for 0.39 percent of GDP 0.39 1.04 al. 2018). Beyond national funding, government engagement with building an SSN system is expressed through (see Appendix A2 for the list of programs included). The two national SSN programs, PACAD and LONDO government management of two donor-funded national SSN programs, PACAD and LONDO. (see description in Appendix A2.2 and Appendix A2.3), 0.00 0.50 1.00 1.50 2.00 In the following subsections, spending trends and the composition of the following four SSN categories in CAR are represented 0.12 and 0.07 percent of GDP respectively detailed: national SSN programs, PACAD, LONDO, and humanitarian programs. in 2019 (figure 6.7). While they are both under the School feeding responsibility of national ministries (MAHRN and LONDO PACAD MEPC respectively), they are financed by World Bank 6.3.2.2. NATIONALLY FINANCED SSN PROGRAMS Other national SSN grants. School feeding programs represent less than Humanitarian programs 0.01 percent of GDP. The main bulk of SSN spending The share of SSN programs financed in the national budget has grown recently, but half of the spending is not consists of emergency and humanitarian support targeted to vulnerable groups. The share of the SSN financed by the government has been growing from 2016 to financed by NGOs and bilateral and multilateral 2019, reflecting government’s engagement toward building a national SSN system. However, the mix of programs partners (1.04 percent of GDP). shows some signs of inclusion errors, as most of the spending is directed toward non-vulnerable groups. In fact, 24% about half of nationally funded SSN programs are higher education scholarships to study in Bangui, as well as SSN spending in CAR is low and has been decreasing outside the country (equivalent to 0.19 percent of GDP) (figure 6.9). Typically, higher education students are less over the last six years. SSN spending represents 1.65 likely to be from the low-income population. Budget data for scholarships in 2020 and 2021 show a decreasing percent of GDP, in line with the SSA regional average trend compared to 2019, but scholarships remain the largest share of SSN spending in the forthcoming budgets. (1.53 percent) and the LIC group average (1.5 percent) (figure 6.8). SSN spending has however decreased Promising SSN programs targeting the poor and vulnerable have recently emerged. The MAHRN is implementing 76% compared to 2016, when it represented 2.6 percent programs for vulnerable households, amounting to 0.14 percent of GDP (figure 6.9). One example is a new cash of GDP. After the donors’ conference in Brussels in transfer program in Berberati along the lines of the PACAD program (see Annex A2.2 for PACAD description), using 2016, the level of humanitarian assistance was in fact mobile phone payments. The program is implemented by the CIFS. Other national SSN programs (0.05 percent of National External GDP) include targeted health subsidies financed by the Ministry of Health (free care for women who are victims of particularly high to respond to the damages caused by years of armed conflict. violence, subsidized treatment for HIV patients, and a state contribution to subsidized vaccinations). Source: Authors’ calculations based on Appendix A2. 143  Data on private pensions are not available, but it can be expected 144 that expenditures are smaller than for the public sector. 145 FIGURE 6.9. COMPOSITION OF NATIONALLY FINANCED SSN, 2019 TABLE 6.1. PACAD CASH TRANSFER PAYMENTS, 2018–20 2018 2019 2020 PACAD CT payments (CFAF million) 740.2 1,572.9 845.1* Nationally 0.05 0.14 0.19 financed SSN % of GDP 0.06 0.12 0.06* Source: PACAD Implementation Unit. 0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.45 * Data for 2020 are partially available (data from the second quarter are not yet available). MSP Targeting subsidies: health MAHRN In-Cash MES Scholarship The PACAD CT could serve as a foundation for scaling up cash transfers in the country. PACAD is an opportunity Source: Authors’ estimation based on Appendix A2. to build the pillars of a SSN system that targets vulnerable populations, including an effective delivery system, a social registry, and a community-based targeting method. Such an SSN system would also allow the government to respond more quickly to climate-related crises, including floods, by identifying and targeting new and existing 6.3.2.3. SSN PROGRAMS IMPLEMENTED BY NATIONAL INSTITUTIONS BUT FINANCED EXTERNALLY— beneficiaries for emergency assistance. The program has the potential to further build institutional capacities in THE CASH FOR WORK PROGRAM (LONDO) AND CASH TRANSFER (PACAD) program delivery and beneficiary targeting, as well as establishing a social registry of beneficiaries. LONDO (‘Stand-Up’ in Sango) is the first national SSN program, and the only one to date to have reached national 6.3.2.4. DONOR-FUNDED SSN PROGRAMS coverage. The project was rolled out in 2016 and by 2020 and was active in all 71 districts of CAR, becoming the largest cash-for-work program in the country. It is administered by MEPC and financed by the World Bank. Most SSN spending in CAR is for emergency and humanitarian programs funded by international partners. LONDO is a peacebuilding project that uses labor-intensive public works (LIPWs) as a means to promote social Most SSN programs are implemented and financed by the humanitarian community, including generally short- cohesion, economic recovery, and local governance. Under the project, participants are paid to work mainly on term and small-scale programs that focus on immediate support. While these programs are a lifeline for the road maintenance (including road surface repairs, drainage system, and so forth), which ensures at the same time population, they are implemented with limited coordination (mostly ex post program monitoring, section 6.2.3 their community connection to essential socioeconomic services (see Appendix A2.3 for program description). above) and do not support building a national SSN system. LONDO is a good example that implementing a nationwide SSN is possible. Even though the program Many actors are involved in humanitarian and emergency programs, leading to high financial unpredictability implementation faced security challenges (requiring support from MINUSCA144 in some regions), spending and potential duplication, jeopardizing the sustainability and efficiency of the system. In 2020, 37 international on LONDO has been growing (reaching 0.07 percent of GDP and 4.4 percent of total SSN spending in 2019). By partners, including NGOs and bilateral and multilateral donors, were financing different interventions for a total 2020, the program’s targets were met, including opening 71 construction sites (one in each district) with 500 of 1.31 percent of GDP. Spending levels have fluctuated across years, from 2.6 percent in 2016 to 1.04 in 2019 (table workers, supporting a total of 35,500 beneficiaries. Currently, the LONDO LIPW activities have been suspended 6.2). The surge of spending in 2020 is led by the implementation of projects responding to the COVID-19 pandemic due to the COVID-19 pandemic and security issues. LONDO has refocused its activities on the production of non- (about one third of humanitarian spending in 2020 were COVID-19 responses). The sustainability of the system surgical masks to be freely distributed to the population. The mask activities created employment for more than is further threatened by the funding volatility, which varies in function of political and financial constraints 3,000 tailors (see Appendix A2.3). LIPW activities are expected to resume once security improves, and the project of the different actors. The large number of partners also argues for setting up pre-intervention coordination envisions another round of public works in each country’s district. mechanisms that could limit project duplication, which undermines the efficiency of the system. PACAD is the second national SSN program, launched in 2017, and the first national cash transfer program targeting vulnerable households. It is administered by the MAHRN and financed by a World Bank grant. It initially included two main components: (i) infrastructure building for displaced and host communities, and (ii) a cash TABLE 6.2. SPENDING ON EMERGENCY SSN PROGRAMS, AND NUMBERS OF PARTNERS, transfer (CT) to vulnerable households. The CT provides timely and regular transfers to selected households 2016, 2019, AND 2020 for a two-year period. They serve as a relief to vulnerable households in areas affected by forced displacement, 2016 2019 2020 helping to fill immediate consumption gaps and preventing negative coping strategies such as selling or loss of assets. With the additional financing in 2020, the CT program is expanding compared to initial plan (AF of US$12 Total spending (CFAF million) 21,765.7 13,584.6 15,740.9 million for component 2), by scaling up coverage to include communities affected by crisis, including COVID-19 and flooding, in addition to forced displacement. The project duration has also been extended until June 2023 % GDP 2.6 1.04 1.31 (instead of 2021 according to the initial project) (see Appendix A2.2 for program description). Number of partners 35 26 37 The PACAD cash transfer is the largest stand-alone SSN program in CAR. Spending on PACAD’s CTs has been increasing and is expected to growth further with the additional financing. The implementation agency tracks Source: UN Cash Working Group for 2019 and 2020, ASPIRE for 2016. benefit payments per semester in each of the implementation areas, which allows accurate estimates of the CT payments. In 2019, CT payments represented 0.12 percent of GDP, or 7.3 percent of total SSN expenditures, making Most emergency SSN programs take the form of a one-off transfer, addressing mainly food security. Most PACAD the largest SSN program in terms of spending. In fact, other SSN spending categories include several small emergency programs aim to ensure food security of beneficiaries, providing one-off support under the form of programs (for example, there are seven different scholarships representing 0.19 percent of GDP, and several dozen food or vouchers. About 85 percent of total spending on emergency programs is in fact addressing food security, programs within the humanitarian and emergency spending). while the remaining 15 percent addresses multisectoral objectives (such as building shelters and improving nutrition). While one-off food security interventions are lifesavers for beneficiaries, their short-term design limits their potential contribution to building resilience and human capital. 146 144  147 The government is also involved in the implementation of a national humanitarian project to support return Coverage of humanitarian programs increased with the COVID-19 pandemic. In 2019, humanitarian and emergency and reintegration of internally displaced persons (IDPs). The PARET project is a government initiative focusing projects reached 12 percent of the population. As a response to COVID-19, the humanitarian community scaled initially (since late 2016) on IDPs living on private sites in Bangui, and since 2019 on IPDs in Kaga-Bandoro and up its support in 2020: it covered 848,000 individuals (17.99 percent of the population), among which 375,000 Bambari. The objective is to support families wishing to leave the sites to return voluntarily to their neighborhoods benefited from specific COVID-19 activities. of origin. The project is funded by the United Nations High Commissioner for Refugees in the Central African Republic (UNHCR). Since 2020, the PARET project has been included in the country finance law (Loi des Finances), A rapid mobile phone survey confirmed the increasing trend in coverage. A mobile phone survey was recently indicating the government’s intention to co-finance the project. No data spending levels were available at the conducted by the National Institute for Statistics, with the objective of measuring the impact of COVID-19 on time of the report, and the project is therefore not included in the SSN spending aggregate. households. The survey offers additional insights and confirms the low coverage of SSN programs, as depicted by the administrative data, but the increasing trend. Overall, 27.2 percent of the population declared having received SSN support since March 2020 (figure 6.10). 6.3.3. Coverage of social protection The analysis of spending on SSN programs reveals that they do not adequately cover the needs of the FIGURE 6.10. SSN COVERAGE AND POVERTY, 2020 (%) population. Overall coverage is low with respect to the needs and coverage gaps remain numerous, because most interventions are short-term responses to shocks. Coverage 17.99 2.8 6.3.3.1. OVERALL COVERAGE TRENDS (administrative) Coverage (Mobile 27.2 phone survey) More than 70 percent of CAR’s population lives in poverty, yet SSN coverage is alarmingly low with respect to the needs and consists mainly of emergency projects. Overall, 20.7 percent of the population receives an SSN Poverty 71 benefit, as estimated in 2020 using administrative data (see Appendix A1.5 for data source), while 71 percent of the 00 10 20 30 40 50 60 70 80 population, representing nearly 3.4 million people, lives on less than US$1.9 per day (World Bank 2020a). Coverage Emergency and humanitarian Safety nets is driven by emergency and humanitarian projects (17.9 percent), and coverage of other SSN programs remains limited (2.8 percent). The administrative data coverage represents an upper-bound estimate: one household Source: Rapid mobile phone survey and Appendix A2 for administrative coverage. Poverty rate is based on estimate from World Bank 2020. may in fact benefit from several interventions and be counted twice as administrative records do not capture Note: The data presented have been collected during the second wave of the mobile phone survey (from March to December 2020), covering programs’ overlap. all regions of the country. In total, 1,180 respondents participated in the survey (representing 240,966 individuals using the population weights). An important drawback of the mobile phone survey is that people who do not own a mobile phone, who are often the poorest The country moved quickly from a situation with zero national programs to programs with significant coverage among the population, are not represented. of national programs in 2020. Since 2016 and 2017, the country started implementing PACAD and LONDO. The LONDO program reached 0.8 percent of the population in 2020 (approximately 500 workers in each district) and is the only SSN program to date that has achieved national coverage (that is, public works with presence in all 6.3.3.2. COVERAGE GAPS AND NEEDS CAR districts). The coverage of the CT PACAD program has rapidly increased since its implementation in 2017, reaching by 2020 1.65 percent of the population (77,880 individuals from 15,576 households). Coverage of national There is a large need for SP in CAR, at different level across population groups and along the life cycle, and programs is expected to further expand in the short run, notably with the additional financing of the PACAD and many gaps remain. The poverty and human capital preliminary diagnosis (based on 2019 estimates, as the latest a new round of LONDO (the final target number of beneficiaries is 129,250 by 2024). household survey was in 2008) calls for some SP responses, according to each group, as summarized in the introduction (section 6.1). The current set of programs leaves many needs unaddressed. At the life-cycle level, few programs have a specific focus on (i) young children (small-scale vaccination waiver) and (ii) school ages children (school feeding program from PAM and UNICEF, as well as potentially regressive higher education scholarships). Risks faced by (iii) adults also remain mostly unaddressed or partially (PACAD and LONDO that provide regular cash transfers/wages, a limited fee-waivers program for women victims of violence, and some income-generating activities, mostly under the PARET project, which focuses on IDPs). There are no formal programs focusing on disabled nor on the elderly (only civil servants are covered by the social insurance scheme). The SP needs and policy implications of the current gaps are summarized in figure 6.11. The policy implications converge toward building (i) SSNs that improve human capital building and (ii) productive SSNs. SSNs could help households protect and improve their own human capital, by increasing the demand for health and education services (such as school feeding programs) and linking programs with accompanying measures (in line with the PACAD program that provides beneficiaries with information on nutrition and hygiene). Productive SSNs have the potential to increase skills and employability, and increase the earning and resilience of poor households. The high exposure to shocks calls for an adaptive and flexible SP—especially for areas of high insecurity and levels of displacement. The high level of displacement (695,000 persons, World Bank 2020) adds another need for SP responses. These households are particularly at risk of poverty, poor living conditions, and poor health and nutrition. Humanitarian projects specifically focus on IDPs and their efficiency could be enhanced by improving coordination. The national project PARET also focus on IDPs and could potentially serve as the building blocks for 148 an adaptive SP system. 149 FIGURE 6.11. SOCIAL PROTECTION NEEDS AND POLICY IMPLICATIONS Coverage is not in line with regional poverty. Coverage gaps remain important and interventions are not in line with the regional levels of poverty (figure 6.12). Three regions, Yadé, Kagas, and Plateau, accounted about 60 percent of the poor in the country (World Bank 2019).145 Most of the humanitarian and emergency support is focused on the West and Central regions of the country (particularly Kaga-Bandoro, Bangui, and Bambari). Some regions benefit from little or no support while facing higher poverty rates, such as Eastern regions. While coverage gaps FAITS CLÉS SUR LES RISQUES are partly driven by security challenges, a better distribution of interventions and resources could be envisioned. Other forms of support, using for instance mobile phone technology, could potentially reduce security risks (see JEU N ES EN FAN TS • Malnutrition : taux élevé de retard de croissance (41 pour cent des enfants de moins de 5 ans), prise en charge au cas par cas par les programmes d’urgence • Mortalité : taux de mortalité infanto-juvénile et taux de mortalité maternelle élevé (829 décès pour 100 000 section 6.3.4). naissances vivantes en 2017) Pas d’intervention • Politiques de DPE : largement inexistantes et seulement 9 pour cent des enfants qui fréquentent le préprimaire. Pas d’intervention (uniquement des mesures d’accompagnement des bénéficiaires du PACAD) IMPLICATIONS POLITIQUES FIGURE 6.12. GEOGRAPHICAL DISTRIBUTION OF HUMANITARIAN SSN PROGRAMS AND • Programmes structurels pour améliorer la nutrition, en s’attaquant aux barrières des côtés de l’offre et de la POVERTY BY REGION, 2019–20 demande • Politique plus globale de la petite enfance Main Cities Poverty Rate (%) 0 - 20 FAITS CLÉS SUR LES RISQUES 20 - 40 40 - 60 EN FAN TS D’ÂGE SC OL AI R E • Faible taux de scolarisation et taux élevé de non-scolarisation : en particulier au collège et au lycée (taux de 39 60 - 80 pour cent et 20 pour cent respectivement en 2019), et taux de non-scolarisation atteignant 30 pour cent dans le 80 - 100 primaire, Interventions partielles (cantine scolaire) • Faibles taux d’achèvement : en particulier chez les filles où le taux est de seulement 34 pour cent dans l’école primaire contre 50,4 pour cent chez les garçons Pas d’intervention • Faible effectif des enseignants : ratios élèves/enseignant très élevés (91 pour cent dans le primaire) Pas d’intervention FORTE EXPOSITION AUX CHOCS • Alphabétisation : Seulement 30,3 pour cent des filles âgées de 15 à 19 ans sont alphabétisées contre 43,1 pour cent des garçons Pas d’intervention. IMPLICATIONS POLITIQUES • Programmes inclusifs pour promouvoir l’éducation (par exemple, cantine scolaire, dispense de frais de scolarité) et mesures pour remédier aux contraintes du côté de l’offre • Fourniture de programmes d’éducation alternative, de secondes chances et de programmes d’alphabétisation FAITS CLÉS SUR LES RISQUES ADULTES • Faible taux de survie des adultes : un des niveaux d’espérance de vie les plus bas (52,9 ans en 2017) Intervention ponctuelle de programmes d’urgence • Pratique prévalente de l’agriculture de subsistance et précarité des revenus : la plupart des ménages consomment ce qu’ils produisent et n’ont pas suffisamment de revenus Interventions partielles (PACAD et LONDO) et quelques activités génératrices de revenus ponctuelles • Inégalités de genre : Les femmes sont confrontées à de fortes inégalités en matière d’éducation et d’autonomisation économique. Résolution partielle (subventions ciblant la santé pour les femmes victimes de violence) • Personnes en situation de handicap : groupe particulièrement à risque de pauvreté Pas d’intervention IMPLICATIONS POLITIQUES • L’ajout d’un volet « promotionnel » à la protection sociale permettrait d’améliorer la mise en relation des ménages pauvres avec des activités de perfectionnement des compétences et génératrices de revenus. • Filets de sécurité sociale adaptatifs qui remédient aux chocs subis par les produits agricoles • Amélioration de la littératie et promotion de l’acquisition de nouvelles qualifications à travers la formation et le travail subventionné, en particulier chez les femmes • Nécessité d’un appui aux personnes en situation de handicap, se présentant sous forme d’aide sociale ou de mesures d’inclusion. FAITS CLÉS SUR LES RISQUES PERSONNES ÂGÉES • Absence de revenu stable et de retraite : couverture des régimes de retraite limitée au secteur public de taille limitée (où ils font l’objet de retards de paiement) Pas d’intervention • Allocations familiales potentiellement faibles (au vu de l’importance des besoins des déplacés internes) Pas d’intervention IMPLICATIONS POLITIQUES • Pensions sociales ciblées • Accès amélioré des personnes âgées aux formations sanitaires Source: World Bank 2020b; OCHA 2020. 145  Including respectively Ouham and Ouham Pende prefectorates; Ouaka, Kemo, and Nana Gribizi prefectorates; and Lobaye and Ombella- 150 Mpoko prefectorates. 151 6.3.4. Effectiveness and efficiency FIGURE 6.13. COMPOSITION OF FIGURE 6.14. COMPOSITION HUMANITARIAN AND EMERGENCY OF SSN BENEFITS REPORTED Does the SSN system do the right thing (effectiveness) in the right way (efficiency)? The effectiveness of SSN SSN PROGRAMS AS SHARE OF TOTAL IN PHONE SURVEY, targeting could be improved by better targeting of interventions, thereby addressing coverage gaps and focusing BENEFICIARIES, 2019–20 (%) % OF RESPONDENTS on the most needy. The efficiency of SSN could be increased by tailoring the type of SSN interventions with the specific context (for example, choosing benefit types that minimize implementation costs) and by reducing fragmentation. 30 25 % of Beneficiairies 2020 61 29 10 6.3.4.1. TARGETING % of population 20 15 In a context of widespread poverty and tight budget constraints, prioritizing interventions is not an easy task. With more than 70 percent of the population living below the extreme poverty line (US$1.9), targeting limited 2019 65 31 03 10 resources means identifying priorities, population groups, categories, or specific regions. The most critical issue 5 in a setting with such large incidence of poverty is to make sure to limit inclusion errors—that is, not to provide 0% 50% 100% 0 SSN benefits to the relatively well-off population and to cover those most in need. Cash transfer Free food Other support Voucher Cash transfer Electronic transfer (in-kind) The nationally financed SSN programs present a risk of regressiveness. About half of national SSN expenditures are for higher education scholarships (post secondary). Such scholarships are known to be regressive, as students Source: Authors’ calculations based on UN Cash Working Group Source: Mobile phone survey 2021. with secondary school diplomas usually come from non-vulnerable families. It is critical to ensure that limited (2020 and 2021). Note: The data presented have been collected during the second national resources are spent on interventions that have high returns on human building capital. Such interventions wave of the phone survey, covering all regions of the country. In total, 1,180 respondents participated in the survey (representing usually target the earlier stages of life (prenatal care, early childhood development, and so forth). 240,966 individuals using the population weights). An important drawback of the mobile phone survey is that people who do not own PACAD is the first SSN program that applies a targeting process focusing on vulnerable households. It uses a mobile phone, who are often the poorest among the population, are not represented. vulnerability and community-based criteria for household targeting. There are three steps in the selection process: (i) all households located in a target area are screened using eligibility criteria related to IDPs and gender; (ii) a survey of these households is conducted, and households are ranked and selected based on poverty levels, phone payments. Mobile payments have the potential to reduce the costs of security challenges related to the characteristics, and capabilities; and (iii) the communities validate the list of beneficiaries. A recent CT program physical transport and delivery of cash, and therefore increase overall efficiency. In addition, providing mobile from UNICEF also uses vulnerability targeting methods, using community and a proxy means-test. phones to beneficiary households would help link them to communication, financial, and education services (such as accompanying measuring messages transmitted via SMS) (World Bank 2020). In the fragile context of CAR, with households facing recurrent shocks and crisis, emergency transfers usually target households based on the localization of the crisis. Precise information on the targeting methods of There is a need to build SSN programs with a medium-term approach, since one-off food vouchers and in-kind humanitarian and emergency programs is not available. However, most interventions are based on geographical support are still the predominant form of assistance. Most emergency and humanitarian programs focus on targeting as a function of identified needs and crisis. Such targeting appears appropriate for responding to food security in the form of vouchers. In 2019 and 2020, only about 30 percent of the beneficiaries were receiving emergency situations, such as food insecurity. CTs. Overall, most programs are short-term responses, which have limited capabilities for building resilience and human capital. A medium-term approach for the SSN, with programs that allow beneficiaries to rely on predictable The targeting of SSN interventions and the coverage gaps at the geographical level may be driven by security transfers, would improve the system effectiveness. challenges. The latter could, however, be mitigated by making use of new technologies, such as mobile phone payments. Transfers received in the aftermath of the pandemic are also mainly in-kind support. Under the mobile phone survey, 27.2 percent of the population reported receiving a benefit since March 2020, with 6.9 percent benefiting 6.3.4.2. PROGRAM TYPES from free food items and only 1.2 percent from CTs (figure 6.14). The remaining support was in the form of in-kind transfers, including buckets, sanitizing gel, masks, and so forth. The type of SSN program implemented (cash transfer, food distribution, or other in-kind transfer) is influenced by security challenges. Cash transfers present many advantages over food or in-kind support, by enabling poor 6.3.4.3. FRAGMENTATION households to spend more on goods (food, clean water, and medicine) and services (health and education) that generate human capital accumulation. However, CT may be difficult to implement in areas affected by armed A first step toward building a coherent SSN system is to take stock of all interventions. The absence of coordination conflicts.146 The LONDO project for instance faced security issues that required the support of MINUSCA for the mechanism exacerbates fragmentation and the risk of program duplication. A take stock exercise would allow the delivery of the daily wage to reduce the risk of theft. The cost associated with ensuring secure delivery of the government to have a clear vision of the activities in the sector, identify gaps and overlaps, assess the available benefits undermines the system efficiency. funding, and build institutional capacities for monitoring. The exercise would then allow the government to frame an SP strategy based on current capabilities and proven interventions. While program evaluations are sparse, the There has been growing attention to electronic transfer of SSN benefits, which appears to be a promising mobile CT in Berberati for example has proven to be effective.147 delivery mechanism given the security context. Over 2019–20, humanitarian and emergency programs using electronic transfers have been increasing. In 2020, 10 percent of SSN beneficiaries were receiving mobile phone payments (figure 6.13). The national CT program (in Berberati) also successfully disbursed benefits through mobile phones. The PACAD, supported by additional financing from the World Bank, has also envisioned a switch to mobile 147  Only LONDO and the national CT program in Berberati have benefited from some sort of evaluation. An impact evaluation was conducted on LONDO, showing several positive impacts of the program, including increased numbers of working days, increased levels of earnings, and increased ownership of productive assets and savings after program participation (Alik-Lagrange et al. 2020). A satisfaction survey on the national CT program was conducted in Bambari by UNOPS (UNOPS 2020). It showed very positive results: 99.62 percent of respondents felt that 152 146  See Gentilini (2016) for a review of comparative evidence of cash versus in-kind transfer in humanitarian situations. the CT had a positive impact on their household and 91 percent said the CT increased their level of consumption. 153 Rationalization of SSNs could reduce inefficiencies and redirect funding toward flagship national programs. 1. Shift national expenditure away from regressive programs; and (short term) Program fragmentation and duplication often occur in a context of weak institutional environment. The numerous SSNs funded by international partners lack coordination and do not use national agencies for programs 2. Redirect spending toward programs that yield high returns on investments. (short term) implementation. Channeling some resources on a national SSN, such as the national CT PACAD, has the potential to reduce inefficiencies and at the same time build institutional capacities. In 2019, PACAD reached 77,888 Axis 2. Put in place the building blocks of a national SP system individuals with 0.12 percent of GDP.148 Scaling-up cash or mobile phone transfers to cover the poor (representing Adopt a coherent SP strategy through a bottom up-approach and move away from short-term projects to build about 3.3 million individuals) has the potential to decrease poverty substantially. In the absence of recent survey an SSN system that includes medium-term interventions. The SP sector is characterized by a plethora of short- data, it is not possible to estimate the potential cost and impact of scaling up CT, but a similar exercise in Burkina term interventions and a lack of common understanding of the sector. There is a need to create a roadmap toward Faso shows that CT spending may reduce poverty by up to 7 percentage points (Vandeninden, Grun, and Semlali building resilience and reducing vulnerability—by adopting a coherent SP strategy based on a programmatic 2019). A programmatic approach to SSN also could also improve the system sustainability. umbrella (‘up’) built on what exists and what works (‘bottom’). While a lifeline for beneficiaries, emergency support is mostly in the form of one-off transfers that are unlikely to build resilience. Predictable transfers over a medium-term perspective would allow households to invest in human capital and reduce vulnerabilities, 6.3.5. Sustainability FIGURE 6.15. SOURCES OF SSN ASSISTANCE henceforth breaking the intergenerational transmission of poverty. SINCE THE COVID-19 PANDEMIC FROM RAPID Spending on the social safety net is volatile and shows SURVEY MOBILE PHONE, 2021 The first step toward building a such a strategy is to take stock of all interventions. The exercise should be led by sustainability issues. More than 75 percent of SSN programs are financed by external partners, mainly a national institution, which would allow building institutional capacity. Overall actions include: under the form of emergency and humanitarian 11% 1. Identify a national institution to lead the stock-taking exercise. The responsibilities of the Inter-Ministerial support. This kind of aid is quite volatile and has been Unit for SSN (CIFS) include the setting up of a monitoring and coordination system, but the system is not yet fluctuating greatly over the past years (section 6.3.1 12% 34% operational. CIFS could potentially lead the stock-taking exercise. (short term) and 6.3.4). The mobile phone survey also reports that international partners are the main source of post- 2. Take stock of interventions currently in place. The stock-taking exercise would give the government a better COVID assistance to households (with only 34 percent overview of the range and types of interventions, and help more accurately size the level of spending in the from national sources, see figure 6.15). 43% sector. (short term) A programmatic approach to the SSN could also 3. Prioritize the needs of the population and align interventions accordingly. Forthcoming household survey Governement NGO International donor Other improve sustainability. Federating interventions data could help identifying priority groups, based on socioeconomic characteristics of the most vulnerable. around one or several large national SSN programs (medium term) Source: Mobile phone survey 2021. has the potential to increase the system sustainability. Note: The data presented were collected during the second wave International partners could directly contribute to the of the phone survey, covering all regions of the country. In total, 4. Adopt an actionable SP strategy that builds consensus in the government and among partners and financing of such a program. The government would 1,180 respondents participated in the survey (representing 240,966 ensures gradual transition from the donor-managed system to a government system. (medium term) individuals using the population weights). An important drawback then be able to plan and secure funding for larger- of the mobile phone survey is that people who do not own a mobile scale programs while using national systems. phone, who are often the poorest among the population, are not The SP strategy should be based on: represented. • Interventions that exist and work in the country context—as identified by the stock-taking exercise and available evaluations, like the evaluation of mobile phone transfers in Berberati; 6.4. RECOMMENDATIONS • Respond to the needs of the populations—as identified by the prioritization exercise; and • Take into account security challenges and use new technologies for benefits delivery when appropriate.149 The recommendations are based on the keys constraints that were identified in the review of SP expenditure. The SP strategy should respond to the coverage gaps (identified in section 6.3.3) and include: Table 6.3 outlines an action plan for each recommendation. It distinguishes recommendations that require • Human capital SSNs to help households protect and improve their own human capital; actions in the short term (within a year) and the medium term (1–3 years). • Productive SSN to increase skills and employability, and increase resilience of households; and The short-term recommendations include two axes: (1) Improve allocative efficiency of national resources, (2) • Adaptive and flexible SP—especially for areas of high insecurity and levels of displacement. Put in place the building block of the SP system (including both short-term and medium-term actions) and (3) 5. Build leadership. Redefine attributions and stewardship toward a national SP system. Identifying a line ministry Increase efficiency and effectiveness of the system. responsible for SSN interventions is key to ensuring leadership. While this process is constraint by the current political context (uncertainty about the government formation), the institution identified as responsible of Axis 1. Improve allocative efficiency of national resources. the coordination mechanism (for instance, CIFS) could act as a key actor. The stock-taking exercise would In a context of tight budget constraints, it is crucial that national expenditures are directed to programs with the facilitate a constructive dialogue with international partners and legitimize the leader of the exercise as the maximum impact on poverty and vulnerability. The current mix of nationally financed SSN programs shows clear main focal point for all SSN matters. signs of regressiveness. In fact, about half of national SSN spending is on higher-education scholarships. These typically have a low impact on poverty alleviation as beneficiaries are usually better off. Priority should be given 6. Invest in system SP tools such as a payment mechanism, unique social registry, and targeting system. to programs that yield high returns on investments, such as those focusing on the early stages of life. Actions include: 149  New technologies have the potential to respond to the security challenge in program delivery and help establish nationwide SSN coverage. Mobile phone transfers appear to lower the risks associated with CTs, and are free of the logistical issues associated with food and nutrition 148  This comprised a CT of CFAF 25,000 per household per quarter (this level of transfer is approximately 10–15 percent of the food consumption distribution programs. Extending Berberati’s mobile phone transfer program to other regions and including a program evaluation would help 154 level of a household of five people); see Appendix A2.2. build evidence for the program’s efficiency. 155 Axis 3. Increase efficiency and effectiveness of the system REFERENCES Build a national SP coordination mechanism. Given the management and institutional context of SP in CAR Alik-Lagrange, A., Buehren, N., Goldstein, M., and Hoogeveen, J. 2020. “Can Public Works Enhance Welfare in Fragile (lack of national strategy, large numbers of international partners, and diffused leadership across national Economies? The Londo Program in the Central African Republic.” Gender Innovation Lab. Washington, DC: World institutions), building a coordination mechanism is crucial. The stock-taking exercise is the foundation of a pre- Bank Group. intervention coordination mechanism. It would allow the government to accurately size the level of potential interventions and increase spending efficiency by reducing duplication. An ex post monitoring function would Beegle, K., Coudouel, A., and Monsalve, E. 2018. Realizing the Full Potential of Social Safety Nets in Africa. Africa identify bottlenecks and delivery constraints (the first medium-term action). The work on SP coordination has the Development Forum series. Washington, DC: World Bank. doi:10.1596/978-1-4648-1164-7. potential to strengthen institutional capacities in monitoring and data collection and ensure national ownership Central African Republic Government. 2019. “Core Diagnostic Instrument. Republique Centrafricaine. Rapport of the SP strategy. Setting up a national coordination mechanism calls for the following actions: Pays.” Central African Republic Government. 2020. “RCPCA Rapport annuel 2019. Plan national de relèvement et de 1. Formalize the SP stock taking as an annual coordination exercise and plan a budget line for the exercise. consolidation de la paix en république (RCPCA). ” (medium term) OCHA. 2020. “RCA: CWG – Cash based initiatives as of January to December 2020.” https://www.humanitarianresponse. 2. Set up a national ex post monitoring system to identify bottlenecks and delivery constraints by comparing info/fr/operations/central-african-republic/infographic/rca-cwg-cash-based-initiatives-january-january-2020 the budgeted and executed spending of SP interventions. The system should build over the coordination UNOPS. 2020. “Enquête De Satisfaction Auprès Des Bénéficiaires De Transferts Monétaires À Bambari – Rapport mechanism and entails annual reports that track levels of spending and beneficiaries for each intervention. D’Analyse.” (medium term) UNDP. 2019. “Do fragile and conflict-affected countries prioritise core government functions? Stocktaking public expenditures on public sector institutions to deliver on 2030 Agenda.” TABLE 6.3. ACTION PLAN FOR RECOMMENDATIONS Vandeninden, F., Grun, R., and Semlali, A. 2019. “The Way Forward for Social Safety Nets in Burkina Faso.” World Bank, Washington, DC. https://openknowledge.worldbank.org/handle/10986/32329 Proposed reforms Time frame Action: What to do concretely Expected impact Institutions World Bank. 2018. “The State of Social Safety Nets 2018.” Washington, DC: World Bank. https://openknowledge. worldbank.org/handle/10986/29115 Shift national Short term • Shift national expenditure away Improve allocative • MAHRN  expenditure away from regressive programs efficiency of national • MES  ———. 2019. “Central African Republic - Systematic Country Diagnostic: Priorities for Ending Poverty and Boosting from regressive • Redirect spending toward resources, given • MSP  Shared Prosperity.” Washington, DC: World Bank Group. https://documents.worldbank.org/en/publication/ programs and programs that yield high returns on potential regressiveness • MPFFPE  documents-reports/documentdetail/459721563221464687/central-african-republic-systematic-country- redirect spending investments of national SP spending • MTEPS  towards programs (half of them goes diagnostic-priorities-for-ending-poverty-and-boosting-shared-prosperity that yield high returns to higher education ———. 2020a. “Central African Republic Economic Update, October 2020: The Central African Republic in Times of on investments scholarship) and tight budget constraint COVID-19 - Diversifying the Economy to Build Resilience and Foster Growth.” Washington, DC: World Bank Group. ———. 2020b. “Central African Republic - Country Partnership Framework for the Period FY21-FY25.” Washington, Take stock of SP- Short to • Identify a national institution to Create a roadmap Need to identify DC: World Bank Group. related interventions medium lead the SP stock taking toward building who will be in to give a better term • Take stock of SP-related resilience and reducing charge of the overview of the interventions (identify the ‘bottom’) vulnerability—by coordination range and types of • Prioritize the needs of the adopting a coherent mechanism interventions, and population (identify the most SP strategy based on a help more accurately vulnerable groups using latest programmatic umbrella size the level of survey data) (‘up’) built on what spending in the sector • Adopt an actionable SP strategy exists and what works that makes consensus within all (‘bottom’). actors involved in the sector • Build leadership Increase efficiency Medium • Formalize the stock taking as an • Increase spending • To be identified and effectiveness of term annual coordination exercise efficiency by the system - Build • Include a budget line for the reducing duplication SP coordination and coordination exercise and identify reporting mechanism, • Set-up a national ex post bottlenecks and under the leadership monitoring system delivery constraints of a national by comparing the institution budgeted and executed spending of SP interventions 156 157 APPENDIXES 158 159 A1. EDUCATION lack of schools in CAR often results in increased physical risks in commuting to and from school such as exposure to GBV, including sexual exploitation, abuse, and harassment (SEA/H). Furthermore, many schools in CAR lack appropriate water, sanitation, and hygiene (WASH) facilities and therefore cannot provide a safe and healthy school A.1.1 Additional notes on the overview of the education system. environment where students, especially girls, can focus on learning. The lack of latrines is substantial: there are no functional latrines in 56 percent of primary schools and this proportion increases to 62 percent in the case of separate-sex latrines. At the secondary level, there is only one latrine per 369 students in public schools on average. Sectoral priorities and goals Lastly, textbooks and learning materials are in scarce supply and their dissemination to schools remains weak. The government, with the financial support of the GPE, and technical support of the World Bank, prepared the ESP CAR has a huge lack of qualified teachers, especially outside Bangui, which proves to be a major bottleneck in 2020–2029. It presents its long-term vision of the sector and it is structured around four strategic axes which are terms of access to education. Student-teacher ratios (STR) are among the highest in the world at both the primary described in figure A1.1 below. and secondary levels. In 2018–19, the average STR at the primary level in CAR was 91, significantly higher than the SSA average of 37. Moreover, the majority of teachers lack the requisite skills and qualifications to effectively Organization of the Education System teach, and they work in precarious conditions. In 2018–19, 63 percent of primary teachers in public schools were community teachers who typically have very little, if any, training. Although the proportion of community teachers is low in Bangui (5 percent), it is much higher in the rest of the country (70 percent). At the secondary level, 66 FIGURE A1.2 PRESENTS A SCHEMATIC REPRESENTATION OF THE CAR’S EDUCATION SYSTEM BY percent of public secondary teachers are temporary teachers (enseignants vacataires); they were paid by the LEVEL, GRADE, AND AGE. government until 2020 but most of them have not received any pedagogical training. FIGURE A1.1. FOUR STRATEGIC AXES OF THE ESP 2020–2029 Key education performance Supply-side constraints CAR has an insufficient number of schools and a huge deficit of classrooms at the primary and secondary levels. For many girls (and boys), there is no school near where they live and many students travel long distances to reach the nearest primary school and even longer to reach secondary schools (or have to find accommodation locally).150 Moreover, about one third of classrooms in public primary schools are inadequate—not in ‘good condition’. The 150  Based on the findings of the field visits conducted in Bamingui-Bangoran and Ombella-Mpoko as part of the CAR 2020 Education Sector 160 Plan. 161 Demand-side constraints A1.2. Additional notes on sector financing Low enrollments especially at post-primary can be explained primarily by households’ financial constraints TFP FINANCING OF ALL SECTORS IN CAR and low returns to education. First, extreme poverty is a critical challenge. As of early 2021, it was estimated that approximately 40 percent of CAR households are in a situation of acute food insecurity (OCHA 2021). The Table A1.2 shows the distribution of external financing (planned and disbursed) by all sectors in CAR. First, the prolonged period of conflicts has resulted in a sharp deterioration in families’ economic situations, which has led execution rate of this spending increased from 32 percent in 2018 to 84 percent in 2020. According to TFPs, the to their inability to pay school fees. Second, returns to education are perceived to be low due to poor quality of low disbursement rate reflects constrains related to insecurity and continued presence of armed groups; the lack education, low employment opportunities, and insecurity, in comparison to opportunity costs of education for of leadership and coordination; the heavy regulation on the work of NGOs; low level of DRM; and more recently, the poor families. Economic opportunities for children and youth are readily available in mining areas of the country COVID-19 pandemic, which led in delays in implementation of several projects. The actual share of total external and girls are required to perform extensive domestic tasks. There are even young people who engage in “negative financing allocated to the education sector stood at 1.6 percent in 2018, 4.4 percent in 2019, and 5.4 percent in mechanisms of adaptation like joining armed groups, use of drugs and participation in other criminal activities.”151 2020. This share is very low compared to the transport sector (25.8 percent), and lower than the health sector Social and gender norms are unfavorable to girls’ schooling. In many communities, a woman’s role is primarily share (7.9 percent). understood as that of a wife and mother with little value placed on her educational attainment. Child brides are much more likely to drop out of school and complete fewer years of education than their peers who marry later. Pregnant girls often leave school and do not return. Moreover, discrimination in schools continues to discourage TABLE A1.2. EXTERNAL FINANCING PROJECT GRANTS AND CREDITS, 2018–20 (CFAF MILLION) pregnant girls from staying in school and teenage mothers from returning to school. CAR is among 24 African countries that lacks a re-entry policy or law to protect pregnant girls’ right to education (Human Rights Watch   — 2018 — — 2019 — — 2020 — 2018). This often leads to irregular enforcement of compulsory education at the school level. % TFP % TFP % TFP   Planned Disbursed funding Planned Disbursed funding Planned Disbursed funding Literacy rates Social sectors 18,443 16,347 24.8% 21,322 20,861 30.5% 47,051 22,600 22.0% Table A1.1 shows literacy rates by age group and gender. As shown, literacy rates are low both among the young Education 3,299 1,055 1.6% 6,593 3,023 4.4% 6,608 5,582 5.4% cohort and old cohort. Women are the most disadvantaged. Project grants 2,439 1,055 1.6% 6,033 3,023 4.4% 5,808 5,513 5.4% TABLE A1.1. LITERACY RATES BY AGE GROUP AND GENDER Credits 860 0 0.0% 560 0 0.0% 800 69 0.1% Health 5,982 7,868 12.0% 9,874 3,836 5.6% 21,176 7,072 6.9% Age Women Men Ratio W/M SP & gender 9,161 7,424 11.3% 4,855 14,002 20.4% 19,267 9,946 9.7% 15-19 30.3% 43.1% 0.70 Defense & public order 5,212 1,348 2.0% 4,290 5,609 8.2% 4,171 4,225 4.1% 20-24 30.7% 57.9% 0.53 Economic affairs 40,610 38,258 58.2% 34,974 31,097 45.4% 54,387 42,265 41.1% 25-29 24.7% 47.9% 0.52 Transport 15,942 29,014 44.1% 10,842 14,549 21.2% 9,384 17,700 17.2% 30-34 21.6% 44.5% 0.49 Energie 12,263 3,583 5.4% 8,598 2,750 4.0% 20,740 10,133 9.9% 35-39 18.5% 44.3% 0.42 Agriculture 3,568 299 0.5% 6,537 4,367 6.4% 12,602 4,862 4.7% 40-44 18.8% 50.8% 0.37 Finance & rel. affairs 8,837 5,362 8.2% 8,998 9,430 13.8% 11,661 9,570 9.3% 45-49 17.7% 43.2% 0.41 General pub.services 1,064 233 0.4% 486 1,075 1.6% 1,017 25,968 25.3% Bangui Metrop Area 68.7% 81.9% 0.84 Others 8,417 9,600 14.6% 3,252 9,865 14.4% 3,196 7,659 7.5% Rest of CAR 13.2% 37.2% 0.35 Total 73,746 65,787 100.0% 64,325 68,508 100.0% 109,821 102,717 100.0% Urban areas (-BMA) 33.4% 59.0% 0.57 Educ. ext. fin Rural areas 7.6% 30.4% 0.25 4.9% 11.9% 18.2% (% of tot. gov. spend. on educ.) Total 24.9% 47.5% 0.52 Source: Authors’ calculations based on data from the Ministry of Economy, Planning and Cooperation (2018-2020) Others include ministries of justice, youth and sports, environment, housing, and culture Source: MICS 2019, authors’ calculations Note: All persons with minimum lower secondary education are assumed to be literate 151  Translated from MEPSTA. 2018. “Des mécanismes d’adaptation négatifs comme l’adhésion à des groupes armés, le recours à la drogue et la 162 participation à d’autres activités criminelles.” Programme Pluriannuel de Résilience (Multi-Year Resilience Programme) 2019–2021; p.1–2. 163 MATRIX OF TFP INTERVENTIONS TFP Subsector Description of Main Activities Period As mentioned in section 4.3.2, TFP supports the education sector via project grants, credits, and budget support. EU ECD • An emergency project that supports the provision of basic services to 2015– Table A1.3 provides the list of projects and a succinct description of projects’ main activities. In addition to these Implementing agency: Primary vulnerable children affected by the conflict through (a) construction/ 2021 projects, the Fonds Saoudien de Dévelopement supports, via credits, the rehabilitation of a secondary school in UNICEF rehabilitation of 54 classrooms in schools and in IDP camps, separate toilets for girls/boys; (b) pre-service teacher training; (c) school feeding Bangui (Lycée Marie Jeanne CARON) and the extension of the University of Bangui. programs; (d) catchup programs and psychological support to teachers and students. Concerning budget support: • Areas of intervention are Bangui and four prefectures (Ombella-Mpoko, Kémo, Nana-Gribizi, and Bamingui-Bangoran). • The European Union series (2018–2019) included six indicators linked to the education system: (i) the adoption of the 2018–2019 Education Transition Plan by the Council of Ministers; (ii) the publication of the 2017–2018 GPE ECD • An emergency project aligned with the government’s education sector 2018– Statistical Yearbook; (iii) an allocation of at least 17 percent of the total government spending (excluding capital Grant Agent for the Primary transition plan (2018/19) focus on emergency interventions such 2021 Education Sector Transition as temporary classroom construction in IDP camps, construction/ spending) to the education sector in the 2019 Finance Law; (iv) an execution rate of the 2018 education budget Plan Support Project: rehabilitation of schools, school feeding programs, catchup programs, equal to or higher than 70 percent (including salary spending); (v) a net enrollment rate of girls in the primary UNICEF distribution of learning materials, hygiene kits, back-to-school education cycle equal to or higher than 70 percent (according to the 2017–2018 Statistical Yearbook); and (vi) campaigns, awareness campaigns, and institutional support. the organization of national exams before August 30, 2019 in at least 96 percent of the planned examination • Areas of interventions are Ouham, Ouham-Pendé, Nana-Mambéré, Ouaka, Basse-Kotto, and Mbomou. centers. However, it should be noted that in 2019, the government did not meet the target as mentioned in (iii), hence the amount of the budget support associated with this indicator has not been disbursed. GPE Primary • An emergency COVID-19 project to support the government in 2020– Grant Agent for the mitigating the impact of the pandemic by focusing on the most 2021 • The proposed IDA-financed CAR First Resilient and Inclusive Institutions for State Effectiveness DPF 2021– COVID-19 project: UNICEF vulnerable children through radio education programs, purchase and 2022 (P175173) will help lay the foundations for successful implementation of the “Plan to Recruit all Graduate distribution of solar radios, awareness campaigns for the prevention and control of COVID-19, as well as catch-up programs for grades 6, 10, Student-Teachers as Contractual Teachers and/or Civil Servant Teachers” by establishing a national registry of and 13 students. all graduate student-teachers (prior action). Establishing a comprehensive database will lay a foundation for the second reform aimed to support the operationalization of the Plan (policy trigger). UNICEF ECD • A series of emergency interventions to cater to the conflict context: 2018– German Development Bank Primary alternative education programs, back-to-school campaigns, school 2021 Education Cannot Wait feeding programs, construction of temporary classrooms on IDP UNICEF Funds camps, expansion/rehabilitation of existing schools, community TABLE A1.3. INTERVENTIONS FINANCED BY PROJECT GRANTS TO SUPPORT THE teacher training, distribution of teaching guides, learning materials, EDUCATION SECTOR and hygiene kits. TFP Subsector Description of Main Activities Period World Bank ECD • An emergency project that seeks to improve access to quality basic 2018– Primary education and strengthen capacity in education sector management. 2023 Secondary Relevant interventions include construction/rehabilitation of African Development Bank Secondary • This multisectoral project (education, health, and SP) supports the 2015– classrooms, in-service teacher training, accelerated education, remedial Multisectoral project with (TVET) construction/rehabilitation of classrooms in three secondary TVET 2019 programs, and institutional support. specific activities related to schools (in the capital city) and in-service TVET teacher training. the education sector • Area of intervention is Bangui. Agence Française de Vocational • This project seeks to offer short-term vocational training and 2019– Développement training apprenticeship training to 2,054 out-of-school youth in 30 key 2022 promising professions. METHODOLOGY TO BREAKDOWN GOVERNMENT SPENDING BY SECTORS Second • Areas of interventions are Bangui and 5 prefectures (Ombella-Mpoko, chance Lobaye, Mambere-Kadéi, and Nana-Mambere and Ouham). Using the 2019–20 budget data, government spending was broken down into five main sectors: social, defense programs and public order, economic affairs, general public services and other (such as housing, environment, justice, youth • A project that will support the provision of employment opportunities 2021– to vulnerable youth, particularly young girls, by improving their 2024 and culture). Using the broad categories of the Classification of the Functions of Government (COFOG) developed employability trough vocational training, apprenticeship, and by by the OECD, ministries were grouped into five main sectors. The classification under this PER is an institutional funding start-ups. classification whereby spending was classified based on the executing ministry. In this case education spending • Areas of interventions are Bangui and 3 prefectures (Lobaye, Nana- was the spending executed by the four ministries of education. Table A1.4 presents the results of this classification. Mambéré, and Mambéré-Kadéi). The expected numbers of beneficiaries are 11,401 young men and 11,687 young women. Ambassade de France Secondary • A project that seeks to transform two secondary TVET schools into (TVET) professional schools (lycée de métiers). A new curriculum will be developed, teachers will be trained, and TVET equipment will be provided. • Area of intervention is Bangui. 164 165 TABLE A1.4. CAR MINISTRIES BY SECTOR TABLE A1.5. ACTUAL GOVERNMENT SPENDING BY SECTOR, AVERAGE 2019-2020 Sector Ministry   — Total spending — — Salary spending — — Staff — Primary and Secondary Education % gov. % total   Million CFAF spending Million CFAF salaries N % total staff Technical Education and Literacy Scientific Research and Technological Innovation Social sectors 39,279 21.4% 14,721 26.0% n.a n.a Higher Education Social Health and Population Education 21,671 11.9% 11,179 19.8% 6,529 22.3% Humanitarian Action and National Reconciliation Labor, Employment, Vocational Training, and Social Protection Health 15,436 8.2% 2,999 5.3% 1,853 6.3% Advancement Women’s and Children’s Affairs Social Protection 2,172 1.2% 543 1.0% n.a n.a Office of the President of the Republic National Defense and Army Restructuring Defense and public order 51,268 28.0% 22,322 39.4% 14,116 48.0% Defense and public order Disarmament, Demobilization, Reintegration of ex-combattants Interior in charge of Public Security Economic affairs 35,404 19.2% 8,957 15.8% n.a n.a Finances and Budget General Public Services 27,605 15.0% 5,744 10.2% n.a n.a Agriculture and Rural Development Water, Forests, Hunting and Fishing Others(*) 29,704 16.4% 4,840 8.6% n.a n.a Livestock and Animal Health Total 183,260 100.0% 56,583 100.0% 29,345 100.0% Public Works and Road Maintenance Development of Energy and Hydraulic Resources Source: Calculations based on data from the Ministry of Finance and Budget (Ges’Co and payroll data 2019-2020) Economic affairs Mines and Geology (*) include ministries of justice, youth and sports, environment, housing, and culture Postal services and Telecommunications Commerce and Industry Communication and Medias ADEQUACY OF SPENDING Small and Medium Enterprises and Handicrafts Transport and Civil Aviation Economy, Planning and Cooperation Current government capital spending is not enough to provide adequate learning and teaching environment to students and reduce student-classroom ratios (SCR) to reasonable levels. Figure A1.3 shows SCR in public primary National Assembly schools. Prime Minister Constitutional Court Economic and Social Council FIGURE A1.3. SCR IN PUBLIC PRIMARY SCHOOLS, TOTAL AND ‘GOOD CONDITION’ BY SI, 2019 High Council for Communication National Mediation Council General public services High Authority in charge of good governance 200 203 General Secretariat of the Government Foreign Affairs and Central Africans Abroad Public service Modernization of Administration and Innovation 150 Administration of Territory, and Decentralization 150 148 147 144 142 Relations with the Institutions of the Republic 132 128 119 119 114 Justice, Human Rights Keeper of the Seals 113 100 112 106 106 100 Advancement of Youth and Sports Other Arts, Culture and Tourism 80 Urbanism, the City and the Habitat 71 Environment and Sustainable Development 50 Source: Authors’s classification using COFOG categories 0 Based on this classification, the level of public spending on defense and public order stood at 28 percent over South Bangui SI Western SI South central East central TOTAL North East SI Central SI Northern SI eastern SI SI SI the last two years (2019–20) in comparison to 21.4 percent for social sectors of which only 11.9 percent was for SCR total SCR 'good condition' education (see table A1.5). Source: Authors’ calculations based on EMIS 2018-2019. 166 167 METHODOLOGY TO BREAKDOWN EDUCATION SPENDING BY SUBSECTOR 2. Second, the wage bill for civil servants who can work either in the primary or in the secondary subsectors is distributed over these two subsectors in proportion to their wage bill calculated above (point 1). This is the Note that based on the current structure of the budget, it is feasible to identify with certainty HER spending, case, for example, for heads of school districts and school counsellors who work in both primary and secondary which is listed under the MES and MSRTI. However, the distribution of spending among the other subsectors was cycles schools. more challenging because the MPSE and METL budget structure does not allow such distribution. Therefore, an 3. Third, the wage bill of civil servants at the central level (civil servants who work at the ministries in charge of algorithm was used to separate spending by subsector. This algorithm comes with a margin of uncertainty on the education) and civil servants whose subsector is unknown (government employees awaiting assignment, civil values found for preschool, TVET, and literacy; but given the low level of spending for these subsectors, it can be servants placed in internships positions, and so forth) is distributed over all subsectors in proportion to the certain that spending in preschool and TVET is low. wage bill calculated above (point 2). The breakdown of the government spending (both actual and planned) on education by subsector was carried out Based on the payroll data, it is impossible to identify civil servants who work in preschool and literacy subsectors in two stages: because there is no teaching rank for these employees unlike the primary and secondary subsectors. Based on consultations held with MPSE units, primary school teachers would teach in preschool or assume the role of 1. Breakdown of government spending into two categories: higher education and scientific research (HER) and instructors in literacy centers. all other subsectors (non-HER); 2. Breakdown of non-HER spending between four subsectors—preschool, primary, general secondary, and Salaries and wages spending for the primary subsector listed under the MPSE budget therefore includes all technical and vocational secondary. preschool (MPSE) and literacy (MTEL)153 civil servants. However, the number of preschool and literacy employees is negligible. Indeed, according to information collected, a minority of preschool teachers would be integrated into the public service, among whom only five teachers would be paid out of the MPSE payroll; the other teachers would Distribution of spending between HER and all non-HER subsectors be instructors or social workers, under the Ministry for the Promotion of Women, Family and Child Protection Government spending on education was broken down as follows: (MPFFPE).154 1. Spending on HER relates to all expenditures of MES and of MSRTI to which were added the expenditure of the The five primary school teachers who teach at the preschool level are used in the algorithm to estimate the share Teachers’ Training College (ENI), currently under the supervision of MPSE. of expenditure allocated to the preschool cycle by the ministries directly in charge of education. The MPFFPE 2. Spending on non-HER subsectors include expenditures for preschool, primary, general secondary, and TVET. expenditure is then added to obtain the total public expenditure for the preschool cycle. They consist of all the expenditure of the MPSE and META. Step 2: adjusted salaries and wages spending Breakdown of non-HER expenditure Adjusted salaries and wages spending ( ) for each subsector were obtained by multiplying the observed proportion of the education wage bill ( ) for each subsector by the salaries and wages expenditures excluding An algorithm was used to breakdown non-HER expenditures into four subsectors: preschool, primary, general HER ( ), as illustrated by the following formula. secondary and technical and vocational secondary education. This breakdown is carried out in four steps:  1. First, the share of each subsector in the education wage bill is estimated based on the payroll data from the MFB. According to the budget nomenclature of the MFB, the payment of contractual teachers (primary subsector) 2. Second, the salary and wages spending is estimated for each subsector using total salaries an spending and temporary teachers (secondary subsector) is recorded as goods and services spending. As part of the ESP, recorded on the MFB budget and the share of each subsector in the education wage bill obtained in step 1. the salary payments of contractual teachers have been reclassified and proportionally distributed over salaries 3. Third, other spending categories—“goods and services” and “capital spending”—are then adjusted based on and wages expenditures of the preschool and primary subsectors. Similarly, the salaries of secondary temporary the results obtained in the previous steps. teachers were proportionally distributed between general secondary and TVET. The adjusted total salaries and 4. Fourth, the total spending per subsector is obtained by summing up values obtained in steps 2 and 3. wages expenditures ( ) is therefore obtained as follows: Each step is described below. where is the total for the wage expenditure for contractual teachers and that of the estimate for secondary Step 1: share of each subsector in the education wage bill (excluding HER) temporary teachers for subsector . The share of the education wage bill152 for each subsector ( ) was calculated by dividing the observed wage bill for all civil servants for a specific subsector ( ) by the total education wage bill excluding HER ( ) Finally, the adjusted value of total salaries and wages expenditures for all subsectors excluding HER ( ) is therefore the sum of salaries and wages expenditures for all non-HER subsectors ( ) and the salaries paid to contractual teachers and secondary temporary teachers. The observed wage bill for each subsector ( ) is calculated as follows:  1. First, the wage bill for civil servants whose subsector is unambiguously identified is calculated. For example, for the primary subsector, this will be the wage bill for primary teachers, assistant primary teachers and school principals. 153  Field visits in the prefecture of Nana-Mambéré and Bamingui-Bangoran revealed that all literacy instructors are either volunteers (churches) or paid by NGOs. 154  Based on the data on the wage bill from the MFB for 2019, out of 353 MPFFPE civil servants, there are only 11 social workers, 7 coaches, and 27 social workers. The wage bill for the teaching staff of the MPFFPE is therefore low, which means that a small proportion of public expenditure 168 152  Excluding HER. is allocated to the preschool subsector. 169 Step 3: adjusted expenditure for other spending categories The high spending on HER is mainly driven by high wages and salaries expenditures and social expenditures. The breakdown of total HER spending shows that, on average, between 2018 and 2020: (a) wages and salaries amounted The adjusted value of goods and services expenditures (excluding the salaries of contractual teachers and to just over CFAF 4.6 billion, which represented 54.9 percent of this subsector spending; (b) social expenditures secondary temporary teachers) and capital spending is obtained by multiplying the value of each spending amounted just under CFAF 3 billion, which represented over a third of ESR expenditures (mostly scholarships— category by the share of the total adjusted salaries and wages expenditures ( ) of each subsector. CFAF 2.4 billion) and 13–14 percent of the total public spending on education; (c) capital expenditures account for only 3.2 percent of HER spending (or CFAF 267 million); and (d) expenditures on research and HER quality activities Step 4: total adjusted spending of each subsector  (computers, library, and so forth) are low standing at CFAF 51 million, accounting for only 8 percent of the “other The total adjusted spending for each subsector equals the sum of the adjusted values of salaries and wages goods, services, transfers and subsidies” (table A1.6). Note that the share of social expenditures in HER spending expenditures (including the salary paid to contractual teachers and secondary temporary teachers) obtained is more than double the average for English-speaking African countries (15 percent).155 in step 2, goods and services (excluding costs of contractual teachers and secondary temporary teachers), and capital spending obtained in step 3. TABLE A1.6. BREAKDOWN OF GOVERNMENT SPENDING ON HER, 2018–20 HIGHER EDUCATION (HER) SPENDING   2018 2019 2020 Total ESR expenditures 8,347 8,256 8,709 Diagnostic of HER spending Wages and Salaries 4,146 5,046 4,706 Government spending on higher education is disproportionally high which is at the expense of key subsectors. Spending on HER represented 40.3 percent of total education spending in 2018, then 37 percent in 2019 and 34 Social expenditures       percent in 2020. The variation in the HER budget from 2018 to 2020 is explained from payment of scholarships arrears. It is worth noting that scholarships are regularly paid late after their scheduled date of payment. For Scholarships(*) 2,431 2,431 2,431 example, scholarship recipients for the 2017–18 academic year who should have received their stipend in 2018 only Food(*) 500 500 500 received it in 2019. The same goes for the 2018–19 academic year; recipients received their scholarships in 2020. Capital expenditures 133 354 313 FIGURE A14. GOVERNMENT SPENDING BY EDUCATION LEVEL, CAR AND SELECTED COUNTRIES Other goods, services, transfers and subsidies 1,137 -74 758 Social expenditure as a % of ESR spending 35.1% 35.5% 33.7% 100% 8.7% Social expenditure as a % of gov. spending on education 14.3% 13.1% 13.1% 16.2% 90% 21.3% 23.0% 23.1% 23.1% 23.7% Source: Calculations based on data from the Ministry of Finance and Budget (2020). 27.5% 28.1% 29.7% Note: The ESR budget includes ENI’s spending 37.3% (*) Planned expenditures 80% 70% 26.0% 16.79% 14.4% Scholarships constitute the bulk of social expenditures and the award process does not favor students from 52.6% 22.9% 29.6% vulnerable families. Scholarships represent about 82.9 percent of social expenditures over the period 2018–20 60% 34.9% 25.52% and target primarily: (a) students enrolled in technical, agricultural, professional, and scientific fields of study; and 14.9% 39.1% 38.3% (b) students who enrolled in an advanced study program: priority is given to doctoral students, then to masters 50% and finally to bachelor’s degree students. There are two types of scholarships in the CAR: internal scholarships, granted to Central African students enrolled in public and private Central African universities; and external 40% scholarships intended for Central African students enrolled in universities outside the CAR, which represent the majority of scholarships spending (61.7 percent). Three main types of criteria are taken into account for 52.5% 61.94% 61.6% 30% the awarding of internal and external scholarships: academic excellence, special criteria, and social criteria. An 52.4% 44.7% 47.6% additional condition is applied for the awarding of an external scholarship: students must be enrolled in a training 35.0% 39.3% 44.71% 20% 26.1% program that is not offered in the CAR. Social criteria take into account, among other elements: the income of the 33.2% household to which the student belongs, the age of the student, and if the student is member of a minority group 10% or has a disability. According to the Directorate General of Scholarships and Internships (DGBS), these criteria are not applied and remain, in practice, imprecise or subjective. For example, as the DGBS does not have the means 5.4% 7.5% 0% 3.7% 0.02% 1.0% 2.7% 2.6% 1.0% 0.2% 0.03% 0.2% to know the exact income of a student’s household; it is based on a proxy: the average standard of living of the Cameroon Niger Burkina Congo, Cote SSA LIC Rwanda Ghana Burundi Central inhabitants of the prefecture where the student comes from. As indicated in section 4.3.4, “Allocative efficiency Faso Dem. Rep. d'Ivoire average average African (exc. CAR) (exc. CAR) Rep. of spending,” HER uses up a lot of resources and expenses relating to the financing of scholarships account for an important item of expenditure in the subsector: 33.7 percent of HER expenditure in 2020 and 13.1 percent of total Pre-primary Primary Secondary HER (including post-secondary) public spending on education. Source: Calculations based on data from the Ministry of Finance and Budget (2019) and Edstat consulted in May 2021 for other countries. 170 155  Rapport général du Forum National sur l’Education—2008 (pp. 100–101). 171 HER spending recommendations expenditures, on the basis of household income. Participation in tuition costs by families who can afford it should vary according to the diploma level162 (license, masters, and doctorate) and should be flexible to To contain spending of this subsector, the ESP recommended to (a) conduct an audit of spending and (b) diversify promote access to certain training courses (or certain groups of students) according to country priorities the sources of funding. (adequacy between qualification supply and demand). Specifically, the HER expenditures audit should particularly look into: Additional notes on external efficiency of spending 1. The relevance and cost/benefit ratio of each training course: a large number of training courses are currently offered at the University of Bangui, with some of them having limited attendance and/or relevance; they could Table A1.7 below shows literacy rates for individuals who have attended primary education. The quality of primary be grouped156 to optimize resource use. education does not seem to have improved recently since the literacy rates of the younger cohort (15–24 years old) who reached grade 6 are still lower than those of the older cohort. These figures clearly state that the MICS 2. Social expenditures (scholarships, student accommodation, food): their allocation criteria will have to be approach for estimating literacy overestimates the proportion of literates given that the approach assumes that specified or redefined in order to improve their targeting157 and efficiency.158 all individuals who attended secondary education are literate. Proposals to diversify HER funding source include the following: 1. Setting up a performance-based contract linking the financing of the University of Bangui to specific TABLE A1.7. LITERACY RATE BY GRADE, 15–49 YEARS OLD performance criteria, to create incentives for quality improvement and/or more efficient resource use. A similar   Women Men Ratio W/M program has put in place at the Cheikh Anta Diop University (UCAD) in Senegal since 2015, and another is in the pipeline at the Félix Houphouët Boigny University in Côte d’Ivoire. Niger is also contemplating introducing a Never attented 0.0% 0.3%   similar approach to improve funding stability and transparency, as well as university management and quality of education.159 Grade 1 0.0% 0.0%   2. Review the organization of research centers within the Bangui University to enable them to carry out Grade 2 0.2% 1.0%   research and consultancy services. These centers could then secure funding from international organizations and the private sector. Their operation would subscribe to principles widely shared by academic centers Grade 3 0.6% 0.6%   worldwide: dissemination and sharing of research results; a commitment to the basic academic mission of Grade 4 0.5% 3.1% 0.15 the university; a steering committee made up of experts; periodic activity reports; and so forth. These research centers could, that way, generate funding for the university while facilitating the development of scientific Grade 5 3.9% 9.1% 0.43 networks and institutional capacity building. Grade 6 12.4% 22.0% 0.56 3. Mobilize funds from the diaspora and external aid organizations. According to the World Bank, private transfers from the diaspora to SSA in 2015 amounted to US$46 billion, that is, 10 times the amount of BMA 11.7% 25.3% 0.46 foreign direct investments. Donations and endowments from the Central African diaspora as well as external Rest of CAR 12.7% 21.5% 0.59 aid organizations could therefore be an important source of funding for scientific research. This type of philanthropy could be encouraged through the creation of trust funds.160 Urban areas 16.4% 25.0% 0.66 4. Develop public-private partnerships: CAR is already involved in this dynamic with the call for proposals Rural areas 11.2% 20.6% 0.54 for the financing of the construction of University of Bangui II. 15-24 years-old 9.0% 18.8% 0.48 5. Increase the financial participation of students in the system costs.161 The financial resources of higher education in the CAR could be increased by increasing tuition fees and/or reducing subsidies for social 25-49 years-old 15.6% 24.1% 0.65 Source: MICS 2019, authors’ calculations. 156  For example, several subjects of the scientific and technical training courses of ENS, that currently attract and enroll few students, could be taught as part of a single common core course with equivalent training courses of the Faculty of Sciences. 157  For example, scholarships to study abroad funded by the Central African Government should be limited. 158  In Botswana, for example, grants for university meals were eliminated, catering services were privatized, and this reform was expected to A1.3. Additional notes on HR management result in significant savings (see Saint 1992). In Burkina Faso, a study conducted in 2005 shows that a student housing program mainly funded by small private developers would be at the advantage of the government: publicly managed student residences cost an average of four times higher the cost of a privately managed Categories of teachers in the education system equivalent (see World Bank 2010). 159  In Senegal, the program was developed and financed in collaboration with the World Bank and other donors. Significant progress has, as such, been made, and a new consensus around the operation of UCAD was reached. All actors adhere to this consensus of progress because they Government-paid teachers in public schools benefit from it. Thanks to this new social pact and a now pacified environment, UCAD is improving its internal efficiency. The other area where progress is noted is teaching governance. The rector is now the Chair of the University Assembly. This body is the forum where decisions relating Permanent teachers are the minority at all levels of education except the tertiary level. They account for only to university policy are made and the daily steering of management is reviewed, critiqued, amended, and corrected, where necessary. around a third of the teacher workforce at both primary and secondary levels and 17 percent at the preschool 160  Electronic platforms that give an organized voice to diaspora members by influencing development choices in their countries of origin already exist. Movement Capital, for example, addresses investment projects focused on development goals selected by the diaspora, ranging level. Below is a description of permanent teachers by level of education. from infrastructure to healthcare. This platform operates in several countries of Africa. See https://www.crunchbase.com/organization/ movement-capital#section-overview. 161  Proposition expressed by the HER subsector group (June 2019). However, for other ministry executives, this proposition would be hard to 172 implement from a political point of view and because it goes against the objective of equity. 162   Registration fees to the first two cycles of tertiary education in CAR (as a percent of GDP per capita) are lower than in other countries of SSA. 173 At the primary level, there are two groups of permanent teachers based on their teaching rank in civil service and Teacher training capacities they both account for 30 percent of the teacher workforce in 2018–19.163 The first group consists of instituteurs who are enrolled with an Upper Secondary Education Certificate at minimum and received a two-year pre-service Recruiting a large number of teachers will require an increase in the capacity of ENI, ENS, and CPRs to provide education at the Bambari teacher training college. The second group consists of instituteurs adjoint or maître pre-service teacher education, especially outside Bangui. In this regard, TFPs provide support under the: (a) World d’enseignement who are enrolled with a Basic Education Certificate at minimum and received a two-year pre- Bank-financed Emergency Basic Education Support Project (P164295), which is expected to build the second service training in one the 10 regional teacher training centers. ENI to train not only primary teachers but also preschool and lower secondary teachers; and (b) GPE-financed Education Sector Plan Support Project (P173103), which is expected to build one new CPR and expand the capacity At the secondary level, there are also two groups of permanent teachers who have received pre-service education of the three existing CPRs to provide training to not only assistant primary teachers but also versatile secondary from the teacher training college for secondary teachers (professeur de collège and professeur de lycée164). They teachers, community teachers, and teachers for the preschool subsector. represented 34 percent of the teacher workforce in general education and 36 percent in TVET in 2018–19. At the preschool level, permanent teachers are made up of (a) primary teachers who are hired to teach at this Teacher recruitment and deployment level; and (b) assistant social workers under the mandate of the MPFFPE. Since 2009, teachers who graduate from teacher training college and centers are no longer integrated Lastly, at the tertiary level, four groups of permanents teachers (69 percent of the teaching force)—assistants, systematically into civil service. Approximately 4,032 teachers were awaiting integration into civil service as of maîtres assistants, maitres de conference, and professeur d’université. May 2021. Table A1.8 provides the number of graduates-students awaiting integration by level of education. Contractual teachers are graduates from teacher training colleges and centers who are awaiting integration into civil service. They are hired on a renewable annual contract basis by the government to help make up for the TABLE A1.8. GRADUATE STUDENT-TEACHERS AWAITING INTEGRATION INTO THE CIVIL SERVICE lack of permanent teachers at the primary level. In 2018–19, they represented 7 percent of the teacher workforce   Number Graduating Cohort year in public primary schools and 5 percent in preschools. Primary     Temporary teachers represented around two thirds of the teacher workforce in general secondary schools and TVET schools and centers and one third at the University of Bangui. They are (a) often civil servants or private Instituteur 1,256 2009 to 2014; 2016 to 2020 sector professionals who provide teaching hours in addition to their main activity; (b) sometimes graduates from Inst. adjoint/maître d’ensgt 2,133 2012, 2015, 2017, 2018, 2020 teacher training institutes who are awaiting integration into civil service; or (c) individuals who wish to become secondary permanent teachers but who have not received pre-service training. Secondary     Secondary teachers (ENS) 643 2012 to 2020 Community or NGO-paid teachers Future 2021 graduate student teachers     Community teachers are hired and paid by parents and NGOs to make up for the shortage of government paid teachers in primary and pre-schools. They are often untrained and with low qualifications, but the education Instituteur 150   system could not be functioning without them. On average, only 7 percent have reached grade 13, 69 percent Inst. adjoint/maître d’ensgt 0   have grade 10 level, and 24 percent have less than grade 10 education level.165 Community teachers represented 63 percent of the teacher workforce in public primary schools and 84 percent in public preschools in 2018–19. Secondary teachers (*) 258   This proportion has increased from 2010–11 when it stood at 42 percent in both public and private schools166 to 58 Total 4,440   percent in 2018–19. Source: Authors’ calculations based on ministerial decrees for awarding teacher’ contract and teacher integration into civil service (2017–21). (*): Assumption based on the last year for which the number of graduates is known Female teachers With the exception of the preschool subsector, female teachers constitute a very small proportion of the teacher One of the key and pressing strategies put forth in the ESP is to implement a plan to recruit all graduate workforce. Less than one in five primary teachers (19 percent) was a woman in 2018–19 and the proportion is student-teachers as contractual teacher and/or civil servant teacher. It was planned that between 2020 and even lower at the secondary (11 percent) and tertiary (8.4 percent) levels. This low proportion is somewhat in line 2024, the government will annually recruit as civil servants about 1,520 graduate student-teachers on average with the proportion of women in public sector employment which stood at 19.2 percent, signaling that women while the remainder will be recruited as contractual teachers. Recruitment of these graduate student-teachers in CAR register low levels of participation in the labor market. On the contrary, 90 percent of preschool teachers were supposed to be done by order of seniority beginning with those who graduated in 2009. It was expected that are women; their proportion is a little lower outside Bangui (85 percent) than in Bangui (95 percent). Given the new graduate student-teachers will first be recruited as contractual teachers, and this contract will be renewed importance of female teachers on girls’ education, it will be necessary to increase the participation of women in every year until their integration into civil service. Then as a second step, starting from 2024, the government was the teaching profession. expected to revert to the virtuous practice of systematically recruiting as contractual teachers and/or civil servant teachers all student-teachers as soon as they graduate from the teacher training institutes. However, implementation of this plan was derailed in light of recent events, and consultations held with the government as part of this PER helped in designing a revised recruitment plan. Due to teachers strikes and the heat of presidential elections, more than one thousand teachers were recruited as civil servants between 163  Teaching rank as recorded in the EMIS should be interpretated based on where the teacher received his training. Instituteurs are those who December 2020 and February 2021. But at the same time, the government cancelled the budget lines used to were trained in teacher training colleges and may not necessarily have been integrated into civil service. This is the same for instituteur adjoint. pay for contractual and temporary teachers with no plan in place to recruit the remaining student-teachers who 164  To be enrolled, future professeur de collège are required an Upper Secondary Education Certificate whereas professeur de lycée are required are awaiting integration. To address these challenges, a revised five-year plan is proposed under this PER and is a bachelors’ degree. 165  Calculations based on EMIS 2018–2019. expected to begin in 2023. The government would recruit on average each year about 1,720 graduate student- 174 166  Calculations based on EMIS 2010–2011. teachers as civil servants and the remainder as contractual teachers. 175 The implementation of this plan will require:   — EMIS 2018-2019 — Budget (payroll/decrees) 1. Restoring and securing all budget lines dedicated for paying contractual and temporary teachers (see wage   Total Public Total -2019 Total -2020 bill section). Other secondary teachers 174 77 66 81 2. Identifying and making a registry of all graduate student-teachers awaiting integration into civil service that Temporary teachers 2,372 1,401 1885(*) 1885(*) are still interested to work as teachers and are likely to be recruited as contractual and/or civil servants. This registry will exclude graduate student-teachers: (a) who have found jobs in private schools or in another Total secondary (excluding PE teachers) 4,622 2,070 2,749 2,580 industry and wish to remain in these occupations, (b) who have emigrated or are deceased, and so forth. Source: Authors’ calculations based on EMIS 2018–2019, payroll data (2019,2020), and data from ministerial decrees for awarding teacher’ Therefore, as part of the simulation model, it was assumed that 80 percent of the 665 ENI graduate student- contract and teacher integration into civil service teachers, 90 percent of the 1,289 CPR graduate student-teachers, and 75 percent of the 458 upper secondary Notes: (*) Data for the year 2017–2018, the latest data available. teachers (ENS graduate student-teachers) and 658 lower secondary teachers (ENS graduate student-teachers) PE stands for Physical Education awaiting integration into civil service (and were not recruited as contractual teachers) will effectively be recruited as civil servants, in addition to the 1,461 contractual teachers at the primary education level. There are many graduate student-teachers at the secondary education level who work in the private sector, hence Teachers’ salaries the lower proportion of those who will be recruited as civil servants in the public sector. Table A1.10 shows salaries of all categories of teachers in CAR by level of education. Both starting and current gross 3. Offering a contract to all these graduate student-teachers (i.e. those awaiting integration into civil service) and salaries are displayed. new graduate student-teachers starting in September 2023 (i.e. beginning of the school year). The contract to be offered to primary teachers will remain the same. Since there is no existing contract for secondary TABLE A1.10. AVERAGE YEARLY STARTING AND CURRENT GROSS SALARIES OF TEACHERS IN teachers, a contract equivalent to a double vacation should be offered (that is a compensation equivalent to CAR IN 2020 that of a primary teacher who is recruited a contractual teacher167) in order to provide the same teaching hours equivalent to a secondary teacher rank.168   Starting salary (CFAF) Average salary (CFAF) Absence of government-paid teacher from their posts. Government-paid teachers are sometimes not at Primary level     their duty station as perceived to some extent through the differences between teachers recorded in the EMIS Government-paid teachers     (supposed to be those in their duty station) and teachers recorded on the payroll and budget. These differences between these two teacher counts can be explained by (i) errors in the EMIS and/or payroll data, and (ii) teachers Instituteur 1,143,554 1,441,007 being paid by the government but absent from their duty station. Instituteur adjoint 1,005,046 1,153,879 Contractual teacher n.a 540,000 TABLE A1.9. COMPARISON BETWEEN THE NUMBER OF GOVERNMENT-PAID TEACHERS LISTED Community/NGO-paid teachers   IN THE EMIS (2018–19) AND PAYROLL SYSTEM (2019–20) Community teacher n.a 9,000 - 315,000   — EMIS 2018-2019 — Budget (payroll/decrees) Secondary level - Government-paid teachers     Total Public Total -2019 Total -2020 Professeur de lycée 1,369,594 1,952,447 Primary level         Professeur de collège 1,246,754 1,557,519 Instituteur 2,687 1,567 1,586 1,366 Temporary teacher n.a 270,000 Principals (with no teaching duties) 765 546 994 1,119 Tertiary level - Government-paid teachers   Other 211 128 19 17 Professeur d’Université 7,604,112 11,109,494 Contractual teachers 840 681 1,461 1,461 Maître de conférence 7,458,108 9,232,913 Instituteur adjoint/maître d’enseignement 1,676 1,277 1,240 1,138 Maître assistant 4,641,445 6,336,170 Total primary (excluding community teachers) 6,179 4,199 5,300 5,101 Assistant 4,389,882 4,950,467 Secondary level         Temporary teacher n.a 4,500 per hour Professeur de lycée 1,279 340 344 355 Source: Authors’s calculations based on the MFB data (Payroll 2017-2020) and the CAR Education Sector Plan 2020-2029 Professeur de collège 797 252 261 259 167   A contractual teacher at the primary education level receives CFAF 60,000 per month for 9 months during an academic year whereas a temporary teacher at the secondary education level receives CFAF 30,000 per month over the same period. Therefore, offering a contract equivalent to a double vacation will be equivalent to a contractual teacher at the primary education level. 176 168  Respectively 18 and 21 hours per week for lower and upper secondary teachers. 177 A1.4. Additional notes on financing needs and sustainability of spending achievable by 2030 in CAR, given the current starting point. Therefore the baseline scenario assumed a target STR of 50, that is, half the ratio currently prevailing in the public sector (STR = 101). The target STR for the two other scenarii are 60 for a moderate level of access to education and 90 for a poor level of access (this is the current INFORMATION ON THE SCENARII (WITH ASSOCIATED TARGETS) USED IN THE SIMULATION MODEL OF THE ESP average level, when taking the private sector into account). The projections employ four scenarii to estimate financing needs of the education sector and associated costs Secondary level and implication on government spending. These scenarii and main parameters on which targets were set are described in Table A1.11: Projections on the number and composition of the teacher workforce used a target on STR of 50 which is below the recommended level as per Mingat et al. (2010) for expanding provision of secondary education (42 and 30 in 1. First, three main scenarii corresponding to three different levels of access to education—high, average, and lower and upper secondary education, respectively). In 2018–19, the STR stood at 54 in public schools, and 72 when low—are considered in the simulation model. These scenarii are based on targets set on the gross access rate STR is calculated accounting for only professeur de collège. As shown in the main section above, reaching a STR of (at the preschool level) or on repetition and dropout rates (at the primary and secondary levels). These targets 50 by 2030, will require training and recruiting a large number of professeurs polyvalent du secondaire (N=2,825 are reflected in the projections of student enrollment. These three scenarii are named based on the level of in 2030), professeurs de college (N=2,563), and professeurs de lycée (N=1,986). Figure A1.5 presents the projected access to education they represent, but each scenario implies reaching a certain level of quality of education. changes in the composition of the teacher workforce in public schools. For example a high level of access to education (low repetition and dropout rates) will be incompatible with a poor level of quality of education (i.e. an extremely STR). 2. Second, comparing the above mentioned scenarii and financing needs of the sector led to designing a “baseline” FIGURE A1.5. BASELINE SCENARIO—PROJECTED CHANGES IN THE COMPOSITION OF THE scenario, which combines certain elements of the three main scenarii to generate a plan that is realistic from a TEACHER WORKFORCE AT THE SECONDARY LEVEL (PUBLIC SECTOR ONLY) financial point of view and consistent in the light of sectorial recommendations of the ESP. 3. Lastly, the other parameters on which targets were set used in the model, in addition to the access rates 3,000 2,825 targets mentioned above are: (a) STR; (b) SCR; (c) number of training institutes; and (d) teacher ranks. 2,500 2,563 TABLE A1.11. SCENARII AND MAIN PARAMETERS OF THE SIMULATION MODEL 2,000 Scenarii/Parameters Description 1,986 1,401 Scenario 1 - High access 1,500 Scenario 2 - Average access 1,000 Scenarii used in the simulation model Scenario 3 - Low access 378 500 Baseline scenario - the median scenario with targets that are deemed feasible and attainable over the next decade 340 0 0 0 Access rate at the preschool 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Repetition and dropout rates at the primary and secondary levels Professeurs de lycée Professeurs de collège & EPS Main parameters on which Prof. de collège polyvalents Temporary teachers STR, SCR targets are set Number of training institutes Source: ESP Simulation Model revised in 2021; EMIS 2018–2019. Teacher ranks Source: MS ESP Preschool level Given the lack of specially trained preschool teachers and the shortage of teachers for all levels of education, a pragmatic strategy is needed to train and recruit the large number of preschool teachers needed to develop ADDITIONAL NOTES ON TEACHERS NEEDED IN PUBLIC SCHOOLS BY 2030–31 the subsector. UNICEF suggests adopting “a transitional strategy by recruiting teachers who may not have the required qualifications or have undergone formal training but who have the necessary qualities to provide Primary level children with a positive learning experience”169 (UNICEF 2019). In order to develop their skills, these teachers Projections on the number and composition of the teacher workforce used a target on STR of 50 by 2030 which is below the Bruns et al. (2003) recommendation of 40 to achieve universal primary education (Bruns et al. 2003). This recommendation, which is based on the academic literature on class size and average STR observed 169  According to the database of the UNESCO Institute for Statistics (ISU 2019; cited in the UNICEF 2019 report), “in low-income countries, barely 178 in countries with a high primary school attendance rate, and is adopted by the GPE, does however not appear half of the teachers in the pre-primary system are trained.” 179 need to be provided with on-the-job mentoring and structured in-service training.170 This transitional strategy Based on the above recommendation, the average values of SCRs (not the lowest values) were targeted at both can be carried out simultaneously with the development of a pre-service training program in which the level of primary and preschool levels to be achieved by 2030. Thus, at the primary level in the baseline scenario (with qualification required for teachers is higher and can be gradually increased according to the financial and human STR=50), the target objective of a SCR equal to 65 corresponds to classrooms used in double shifts in one half and resources available.171 30 percent of cases,173 respectively. In preschool, a SCR of 45 associated with a STR of 30 implies that one third of students use a classroom (either in preschools or primary schools) in double shifts. As shown in figure A1.6 below (per the baseline scenario), expanding the provision of preschool education will require: (a) training many teachers in the CPRs and ENI in order to have 4,813 permanent teachers in public preschools in 2030–31, whereas there were only 61 in 2018–19; and (b) still relying on community instructors MACROECONOMIC OUTLOOK (moniteurs communautaires; N=632). TABLE A1.12. GOVERNMENT REVENUES AND EXPENDITURES FORECASTS FOR THE PERIOD FIGURE A1.6. BASELINE SCENARIO—PROJECTED CHANGES IN THE COMPOSITION OF THE 2020–30 TEACHER WORKFORCE AT THE PRESCHOOL LEVEL (PUBLIC SECTOR ONLY)     2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 3,000 GDP at current prices Billion CFAF 1,359.9 1,360.0 1,442.9 1,553.7 1,671.9 1,798.7 1,934.9 2,075.3 2,219.5 2,377.7 2,541.9 2,715.3 Annual growth rate 2,500 4.5% 0.0% 3.5% 5.0% 5.0% 5.0% 5.0% 4.8% 4.7% 4.5% 4.3% 4.2% 2,431 of real GDP GDP deflator, 2,000 2.8% 2.0% 2.5% 2.5% 2.5% 2.5% 2.5% 2.3% 2.2% 2.5% 2.5% 2.5% annual inflation rate 1,783 1,500 Annual growth rate 2.7% -1.8% 1.6% 3.0% 2.9% 2.8% 2.8% 2.6% 2.4% 2.3% 2.1% 2.0% of real GDP per capita 1,000 % of GDP 18.0% 21.8% 18.0% 18.3% 18.1% 17.7% 17.4% 17.3% 17.3% 17.2% 17.0% 16.9% 632 Total Revenues 48 Billion CFAF 244.8 296.2 259.4 283.6 302.2 318.5 336.9 359.5 383.8 408.0 433.1 459.3 500 220 599 13 % of GDP 8.5% 8.5% 9.3% 10.2% 10.7% 10.9% 11.1% 11.3% 11.5% 11.6% 11.8% 12.0% 00 Domestic financing 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Billion CFAF 116.1 115.7 133.9 159.0 178.6 195.8 214.4 234.3 254.5 276.5 300.1 325.5 Instituteurs Moniteurs Agents d'éducation Community teachers % of GDP 9.5% 13.3% 8.7% 8.0% 7.4% 6.8% 6.3% 6.0% 5.8% 5.5% 5.2% 4.9% External financing Source: ESP Simulation Model revised in 2021; EMIS 2018–2019. Billion CFAF 128.7 180.5 125.4 124.6 123.6 122.7 122.5 125.1 129.4 131.5 132.9 133.9 % of GDP 16.6% 24.3% 19.3% 18.6% 18.6% 18.8% 19.0% 18.7% 18.6% 18.3% 18.2% 18.0% Total Expenditures ADDITIONAL NOTES ON CLASSROOMS NEEDED BY 2030 Billion CFAF 225.7 330.2 278.3 289.5 311.4 338.9 367.9 388.2 411.9 435.8 462.1 487.6 % of GDP 10.7% 12.8% 11.4% 11.0% 11.1% 11.1% 11.1% 11.0% 10.9% 10.8% 10.7% 10.6% Estimations based on EMIS indicate that overcrowded classrooms result from the shortage of teachers rather Current expenditure (excl. public debt) than shortage of classrooms. For example, only 42 percent of classrooms in “good condition” are used as single Billion CFAF 146.1 174.7 164.8 171.6 184.8 199.6 214.9 228.6 242.6 256.6 272.1 287.1 shifts and at least 10 percent of schools are in fact a cluster of multiple schools using the same location. Therefore, % of GDP 5.5% 11.1% 7.5% 7.3% 7.3% 7.5% 7.6% 7.4% 7.3% 7.3% 7.2% 7.1% the ESP recommended the following: Capital expenditure Billion CFAF 75.0 150.6 108.5 113.0 121.9 134.1 147.3 153.7 163.1 172.5 182.9 193.0 1. First, the government should consider increasing the intensity of using classrooms on a single-shift basis172 (by recruiting new teachers), and to focus construction and rehabilitation efforts on schools where classrooms are % of GDP 12.3% 15.1% 13.7% 13.3% 13.5% 13.7% 13.9% 13.6% 13.5% 13.3% 13.2% 13.1% both overcrowded and overused (several shifts combined with a large number of students). Total expenditures (excl. external financing) Billion CFAF 167.8 205.2 197.3 207.4 225.3 246.2 269.0 282.2 299.5 316.8 336.0 354.5 2. Second, in the longer term, the government should increase the number of classrooms so as to use them only in single shifts while increasing school time at the same time. Source: Ministry of Finance and Budget; Debt Sustainability Analysis (IMF and WB projections) April 2021; ESP team projections 170  The UNICEF (2019) report (“A World Ready to Learn”) further notes that “on-going professional development and relevant in-service training are more effective and less costly in the long run than hiring qualified teachers.” This argument is based on the following sources: (i) OECD 2018; (ii) Namit 2017. 171  As noted in the UNICEF (2019) report, “it is illusory to simply demand a high standard of education for teachers. In Uganda, teachers in the pre-primary system must have completed secondary education. Given the low number of young Ugandans graduating from secondary school each year, 80 percent of them would need to teach in a pre-primary school to ensure that all children receive pre-primary education. Even in countries with enough graduates, the cost of attracting them to work at the preprimary level may be too high.” 172  Classrooms which could be used more (change from single to double-shift) are those located in areas where the demand is high (classrooms 173  It is not possible to consider using all the country’s classrooms in double-shift because many are located in sparsely populated areas where 180 are little used in low-density areas simply because there are few students) but is constrained by the shortage of teachers. the numbers of students and teachers allow only one shift. 181 Implications for government spending on education TABLE A1.14. PROJECTED PUBLIC SPENDING ON EDUCATION 2021–2030, BY SUBSECTOR Achieving the baseline scenario requires increasing progressively total public spending on education, as a     2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Average 2021-2030 proportion of GDP, from the average value of 1.9 percent during 2018–20 to 3.3 percent in 2030. This also has implications for the evolution of spending by category and by subsector as described below. The breakdown of % tot. spending on educ. 41.2% 39.8% 40.4% 39.1% 38.0% 37.9% 37.3% 36.9% 36.4% 36.3% 38.3% Public spending public spending on education into current and capital expenditures and by subsector are presented in table A1.13 on primary and table A1.14 below, respectively. education CFAF million 12,535 14,395 16,165 18,289 18,593 20,193 20,977 22,329 23,849 25,863   Public spending % tot. spending on educ. 21.3% 23.3% 21.9% 23.3% 24.9% 26.1% 26.9% 27.8% 28.6% 28.9% 25.3% on secondary TABLE A1.13. PROJECTED PUBLIC SPENDING ON EDUCATION 2021–2030, BY CATEGORY education CFAF million 6,498 8,435 8,765 10,895 12,159 13,914 15,104 16,850 18,744 20,612   Moyenne % tot. spending on educ. 3.1% 3.6% 4.2% 5.8% 4.3% 4.1% 3.9% 3.8% 3.9% 4.0% 4.1%     2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2021-2030 Public spending on TVET T. spending on % of GDP 2.2% 2.4% 2.6% 2.9% 2.9% 3.0% 3.0% 3.1% 3.2% 3.3% 2.9% CFAF million 940 1,299 1,674 2,708 2,093 2,187 2,180 2,301 2,531 2,846   education (inc. external Million CFAF 30,449 36,195 40,043 46,803 48,888 53,324 56,178 60,522 65,604 71,324   % tot. spending on educ. 4.2% 6.9% 8.0% 8.3% 8.6% 9.2% 9.6% 10.2% 11.1% 12.0% 8.8% Public spending financing) at c.p. 2020 on preschool education CFAF million 1,280 2,508 3,190 3,885 4,205 4,912 5,384 6,183 7,274 8,533   Current %government 14.7% 15.1% 15.9% 17.1% 18.3% 19.2% 20.6% 22.0% 23.6% 25.5% 19.2% expenditures current expenditures Tot. spending on % tot. spending on educ. 69.8% 73.6% 74.4% 76.4% 75.8% 77.3% 77.7% 78.8% 79.9% 81.1% 76.5% Million CFAF 23,563 24,711 27,307 31,015 34,803 37,970 42,265 46,618 51,700 57,431   education (excl. at c.p. 2020 ESR-FPA) CFAF million 21,253 26,637 29,795 35,777 37,050 41,206 43,645 47,663 52,397 57,855   Wages and % total spending on 61.3% 53.6% 52.9% 50.9% 54.3% 53.9% 56.5% 57.5% 58.4% 59.3% 55.8% salaries education Current % tot. gov. current 9.3% 9.7% 10.5% 11.7% 12.8% 13.8% 15.2% 16.6% 18.2% 20.2% 13.8% spending spending excl. debt Million CFAF 18,654 19,391 21,199 23,838 26,535 28,732 31,746 34,775 38,316 42,265   (exl. ESR- at c.p. 2020 FPA) CFAF million 14,942 15,894 17,983 21,152 24,353 27,279 31,168 35,215 39,971 45,449   Goods and % education current 20.8% 21.5% 22.4% 23.1% 23.8% 24.3% 24.9% 25.4% 25.9% 26.4% 23.9% % tot. spending on educ. services expenditures Capital 29.7% 40.3% 39.6% 40.9% 34.3% 33.8% 28.6% 26.1% 23.7% 21.4% 31.8% spending Excl. HER-VET-Literacy (exl. ESR- Million CFAF 4,909 5,320 6,109 7,177 8,268 9,237 10,520 11,843 13,384 15,166   FPA) at c.p. 2020 CFAF million 6,311 10,742 11,811 14,625 12,698 13,927 12,477 12,448 12,426 12,406   Capital % total spending on 22.6% 31.7% 31.8% 33.7% 28.8% 28.8% 24.8% 23.0% 21.2% 19.5% 26.6% % tot. spending on educ. 1.1% 1.1% 1.3% 1.4% 1.7% 1.7% 1.7% 1.7% 1.7% 1.7% 1.5% expenditures education Public spending on FPA CFAF million 327 415 532 673 839 903 982 1,059 1,143 1,224   % government 6.5% 10.7% 11.3% 13.0% 10.8% 11.6% 10.1% 9.8% 9.4% 9.2% 10.2% capital expenditures % tot. spending on educ. 29.1% 25.3% 24.3% 22.1% 22.5% 21.0% 20.6% 19.5% 18.4% 17.2% 22.0% Public spending Million CFAF 6,886 11,485 12,736 15,787 14,085 15,354 13,913 13,905 13,904 13,893   on ESR at c.p. 2020 CFAF million 8,869 9,144 9,716 10,352 10,999 11,214 11,551 11,800 12,063 12,245   Government % government 14.2% 15.0% 15.9% 16.8% 17.6% 18.5% 19.4% 20.3% 21.1% 22.0% 18.1% Tot. spending revenue on educ. CFAF million 30,449 36,195 40,043 46,803 48,888 53,324 56,178 60,522 65,604 71,324   (inc. ext. spending on Million CFAF 30,449 36,195 40,043 46,803 48,888 53,324 56,178 60,522 65,604 71,324   financing) education at c.p. 2020 Financing gap Million CFAF 3,205 6,545 6,785 9,395 6,935 8,169 7,080 7,575 8,465 10,101 7,425 Source: ESP Simulation Model revised in 2021. at c.p. 2020 Note: Prices are in constants value, base 2020. Million USD 5.9 12.0 12.5 17.3 12.8 15.0 13.0 13.9 15.6 18.6 13.7 at c.p. 2020 % total spending on 10.5% 18.1% 16.9% 20.1% 14.2% 15.3% 12.6% 12.5% 12.9% 14.2% 14.7% education % government 1.7% 3.3% 3.2% 4.2% 2.9% 3.3% 2.8% 2.9% 3.1% 3.6% 3.1% expenditures (exc. External financing) % external financing 4.6% 9.2% 9.3% 12.5% 9.0% 10.2% 8.5% 8.8% 9.5% 11.0% 9.3% Source: ESP Simulation Model revised in 2021. Note: Prices are in constants value, base 2020. 182 183 A1.5. Data used for the analysis Grassroots Communities 1) have therefore been taken into to determine the total amount of project grants awarded to the education sector.174 MAIN DATA SOURCES UPDATES PROVIDED TO THE SIMULATION MODEL OF THE ESP 2020–2029 Data used for the education chapter were taken from multiple sources, and the analyses were done with the most recent data and information available. These include: The strong impact of the COVID-19 pandemic and 2020–21 elections turmoil on the government revenues and education sector are taken into account in the revised version of the ESP simulation model. Most importantly, 1. Household survey data, namely the Multiple Indicator Cluster Surveys (MICS) 2000, 2006, 2010, and 2019; and the realization of all the ESP targets originally planned for 2029 have been postponed by one year, and the final the Enquête Nationale sur les Monographies Communales (ENMC) 2016. target for the proportion of spending on education in total government spending has also been reduced by one 2. The Education Management Information System (EMIS) for 2018–2019 and the 2010–2011 Statistical Yearbook percentage point (22 percent instead of 23). 3. Budget data extracted from Ges’Co for the period 2012–20 on domestically financed expenditures from the MFB The impact on the education system of the near absence of schooling for about a year has been taken into account 4. External financing data for the period 2018–20 from the MEPC in the simulation model as follows: 5. Payroll data extracted from GIRAFFE for the period 2017–20 from MFB 1. A negative impact on repetition and dropout rates in 2020–21 of +25 percent and a hysteresis effect (this 6. Learning outcomes data from the 2018–2019 EGRA conducted in the Bangui school inspectorate as part of the shock only gradually decreases). Education Sector Plan 2020–2030 2. The increase in the number of teacher training institutes (ENF, CPR etc.) has been postponed by one year. 7. The World Development Indicators (WDI), the World Economic Outlook (WEO), the UNESCO Institute of 3. The target for STR in secondary schools in 2030 has been revised upwards, from 47.5 to 50, to take into account Statistics (UIS) consulted in May 2021, and the World Population Prospects (2019 revision) the shock of not hiring temporary teachers in 2020–21. 8. Projections data on macroeconomic variables for the period 2021–30 from the IMF and the World Bank 4. It is assumed that only an average of 8 percent of the classroom constructions planned for 2020–21 has been 9. Education Sector Plan Simulation Model for projections on the key variables of the education sector (enrollment completed (estimate based on the EBESP). of student, teachers, classrooms, and associated costs, etc.) 5. The remaining parameters used in the simulation model for the 2020–21 school year are considered to be the same as they were in 2019–20 (i.e. there is no improvement as it was anticipated when the simulation model was developed in 2019–20). LIMITATIONS OF THE DATA Finally, the following information is taken into account: The limitations encountered are as follows: 1. There was no enrollment of student-teachers in CPRs in 2020–21 and 2021–22, as opposed to what was planned 1. The greatest challenges in carrying out the empirical analysis using the administrative data collected was the in the initial version of the simulation model. inability to link different datasets. For example, there are discrepancies between the information provided on 2. The number of teachers recruited in 2020–21 and new information from the payroll data 2017–20. the payroll data and wages and salaries as recorded on the budget data extracted from Ges’Co, constraining the analysis on the wage bill. 2. The current budget nomenclature does not allow tracking of the budget allocation at the regional level and A2. SOCIAL PROTECTION cannot be disaggregated by level of education. The lack of an integrated and effective data collection process within the different entities of the sector is a critical weakness of the system that has direct repercussions on the validity and accuracy of policy making. A2.1. SP spending in CAR: administrative data collection and sources 3. External financing is also classified based on the implementing ministry and as such does not allow to There is no official SP estimate in CAR. Computing the SP spending aggregate is complex as it involved several distinguish funding by sector. constraints: (1) there are different types of SP interventions, (2) there are many actors, and (3) there are no reporting 4. Another challenge was the inability to receive usable data on retirement costs and database on contractual or monitoring mechanisms that track SP interventions in the country. Most SSN programs are externally financed, and temporary teachers: and when data is available, it is often under the form of aggregated expenditure, including both administrative • It was not feasible to ascertain how much a retired teacher costs to the government and how the government and spending on benefits (what goes into hands of beneficiaries). Disentangling administrative data from the plans to pay for such future costs, etc. benefits is a key element to estimate the SSN spending in the country. Additionally, program expenditure data • Payroll data on contractual and temporary teachers who are paid from a specific budget line, with a from donor agencies are often available for the project duration (usually several years), leading to annual averages particular dataset, which is different from the payroll budget line. of SSN spending rather than actual disbursements per year. Section A2 below offers an estimate for the annual SSN spending in 2019, focusing on benefits only. The source of data varies by program, as well as the method used to estimate SSN spending, as detailed below: ADJUSTMENTS MADE TO THE DATA FOR THE ANALYSIS For the purpose of the analysis of spending in the education sector, two main adjustments were made and are A1. National programs financed by international partners: presented below. PACAD: Spending on the Service Delivery and Support to Communities Affected by Displacement Project (PACAD) In terms of economic classification three spending items were adjusted in the following manner: project has been accurately estimated using monitoring data on CT payments (see program description in 1. Textbooks and learning materials as “goods and services” instead of capital expenditures. Appendix A2.2). The implementation unit of the PACAD tracks all CT payments by district (sous-prefecture) from 2. Salaries of contractual and temporary teachers as “salaries and wages” instead of goods and services. May 2018 to November 2020 (see summary of spending by trimester and region in PACAD description below). The 3. In terms of external financing in the education sector, project grants were classified as education projects national SSN aggregate includes PACAD spending from 2019. based on the project’s objective. In addition to these education projects (such as the World Bank-financed Emergency Basic Education Support Project), multisectoral projects that appear to be “mostly” focused on education (such as the African Development Bank-financed Support Programme for the Reconstruction of 174  Conversely, the amounts of projects in which the component related to the education sector is the minority are not included in the total 184 value of direct support to this sector. 185 LONDO: The Implementation Status Results Reports (Bance 2016, 2017, 2018; Fraiji 2020a,b; Fraiji 2021) from the A3. Donor-financed SSNs: World Bank present the cumulative numbers of LIPW beneficiaries, in terms of worked-days. The cumulative numbers of LIPW beneficiaries have been multiplied by the daily salary, to obtain the cumulative expenditure since Other SSNs funded and implemented by donors have been identified, including: (1) school feeding programs, the beginning of the project in 2016 until June 2020, which was then divided by the numbers of years. In addition to started in 2017 by the World Food Programme (Programme Alimentaire Mondial—PAM) and UNICEF; and (2) a stipends, beneficiaries receive a bike after completion of the 40-day contract (see program description in Appendix set of trainings, income generating activities (activité génératrices de revenue—AGR), and agricultural inputs A2.3), which represents an in-kind benefit. The latter has been estimating using the price of the bike from the project distributions. Annual data on the school feeding program is partially available: only school feeding financed by procurement plan (CFAF 65,000) and multiplied by the number of cumulative number of LIPW beneficiaries, and UNICEF in 2019 is included in the SSN spending estimate. PAM school feeding data is not available for 2019 (the then divided by the number of years. A detailed description of LONDO is available in Appendix A2.3. PAM school feeding budget was US$7.6 million in 2018, for an estimated 100,000 children (MEPC 2018). Training and AGR activities have been estimated using data reported in the annual report of the RCPCA in 2020 (Central African Republic Government 2020). A2. Nationally financed SSN interventions: Nationally financed SSN interventions (next to PACAD and LONDO) have been estimated using executed budget A4. Humanitarian projects: data of 2019 and 2020. More specifically, we reviewed intervention expenditure of all ministries (not only MAHRN, MPFFDE, and MTEPS) and included in our estimate those directly linked with SSN. The SSN aggregate relates to There are a large number of emergency and humanitarian projects from NGOs and bilateral and multilateral donors 2019 executed spending only (as 2020 executed spending data was not available). The following interventions are reported under the Cash Working Group from the United Nation Office for the Coordination of Humanitarian included in our SSN aggregate: Affairs (OCHA). The Cash Working Group collects information on program spending and beneficiaries per semester, covering 26 partners in 2019 and 37 in 2020. From MPFFPE: • 2 social care interventions targeting mothers and children (Direction de la Petite Enfance et de la Solidarité Next to activities recorded under the OCHA Cash Working group, the “Return and Reintegration Support Project in and Centre de la Mère et de l’Enfant) (not executed in 2019) the Central African Republic” (PARET) is a large-scale national humanitarian project. The project started in 2017, • 1 social care intervention targeting blind and deaf beneficiaries (Centre de Formation des Sourds Muets et under the management of the Ministry of Humanitarian Action and National Reconciliation and with the financial Aveugles de Ben-zvi) (not executed in 2019) support from UNHCR. The project aims to support the voluntary return of internally displaced persons to their • From MSP: areas of habitual residence by ensuring that the return takes place in safety and dignity with particular attention • Health targeting subsidies (free care for women victims of violence, subsidized treatment for HIV patients, and to vulnerable people. The main activities over 2017–20 were the closure of more than 43 IDP sites including 32 state contributions to subsidized vaccinations) sites in Bangui. The closure of camps was accompanied by mostly one-time financial support for the return of 23,189 households (50,227 people), over the period 2017–20. From MES: • 7 scholarships programs for higher education (including 3 for studying abroad) A5. LM data: From MAHRN: LM data includes spending on training and income-generating activities (activité génératrice de revenu–ARG). • 1 cash transfer for displaced community members (PACAD). Following the PACAD model, the MAHRN has Information come from the annual report of the National Recovery and Peacebuilding Plan for the Central financed a CT using mobile phones in Berberati. African Republic Mutual Commitment Framework (Plan national de relèvement et de consolidation de la paix • 7 interventions to vulnerable households (2 for victims of natural disasters) en république centrafricaine et du cadre d’engagement mutuel—RCPCA-CEM 2017–2021). The PARET project also • 5 interventions supporting activities of NGOs and local associations includes income-generating activities for IDPs reintegration. In 2019, 20 associations carrying income-generating activities provided financial support for the implementation of socioeconomic activities to 300 returnees. TABLE A2.1. NATIONALLY FINANCED SSN INTERVENTIONS A6. Coverage: Ministry Program type Program category Budget 2019 Executed 2019 Budget 2020 Budget 2021 Coverage is estimated using available administrative data. It includes coverage from all humanitarian projects, MPFFDE Social care For children and mother 20,000 0 5,000 5,000 PACAD, and LONDO. Coverage from nationally financed SSN programs is partially available only (3,200 households services benefited from the mobile phone CT, representing approximately 16,000 individuals). Note that coverage of LONDO MPFFDE Social care For disabled (blind and deaf ) 15,000 0 16,000 0 is estimated using the total of direct beneficiaries of the public work (those who are hired under the program) services over the four years (2016–20) of the program implementation (see Appendix A2.3 on LONDO). PACAD coverage, including direct and indirect household members, reached 77,880 individuals (equivalent to 15,576 households) (see MSP Food/in-Kind Targeting subsidies: health 700,000 700,000 530,000 130,000 Appendix A2.2 on PACAD). The humanitarian and emergency-related coverage has been estimated at the individual level using UN Cash Working Group reports. Coverage from PARET has been estimated taking into account the 2019 MES In-Cash Scholarships 3,410,000 2,460,016 2,675,000 2,275,000 coverage (1,702 households, representing 6,012 individuals), and included in humanitarian coverage. MAHRN  In-Cash Support to NGOs and local 410,560 407,450 310,000 155,000 association (for program implementation) A2.2. PACAD description MAHRN  In-Cash PACAD 550,000 550,000 550,000 550,000 The Service Delivery and Support to Communities Affected by Displacement Project (PACAD) project started in 2017, with the objectives of alleviating poverty and improving living conditions and economic opportunities for MAHRN  n.a. Support to vulnerable 900,560 895,506 1,016,219 841,219 both IDPs and host communities. It consists of two main activities: the provision of safety nets (component 2); households and improvements in services and investments in infrastructure (component 1), which also lead to temporary job creation. It also includes community mobilization, capacity building, technical assistance, and project management 186 Source: Compiled from Executed 2019 and Loi des Finances 2020. 187 related to the implementation of activities in component 1 and 2 (component 3). The project is financed by the World Beneficiaries: Bank (initial cost of US$28 million over 2017–21, with US$15 million for component 1, US$8 million for component 2, and $5 million for component 3). PACAD has been scaled up by an additional financing (AF) in 2020–21 (IDA grant of 2017 2018 2019 2020 2021 (AF) US$16 million) to support the government’s effort to mitigate the impacts of crises, such as COVID-19 and ongoing flooding, and promote stability, while building the government’s capacity to manage safety net programs. Households 1,000 8250 15000 15,576 Component 1: The project initially focused on building infrastructure and investments that can benefit both the Individual 5000 63,250 77,660 77,880 displaced and the host communities. Infrastructure investments focus on a mix of basic services, urban roads, and % of female 60 60 53 63 roadside drainage that can benefit the general population, have limited maintenance requirements, and are labor intensive. Over 2017–21, several projects are taking place, from the construction of urban roads in Bambari, to the % of displaced 80 56 80 rehabilitation of the Bangui PK5 Madou and Kokoro drainage system collection, and the Bambari city hall park, and solar streetlamps in Kaga Bandoro and Paoua. Ongoing projects are expected to be finalized by June 2021. Locations Bambari Bambari and Bambari, Kaga Bambari, Kaga Bambari, Kaga Bandaro, Paoua, Kaga Bandoro Bandoro, Paoua Bandaro, Paoua, Bangassou, + Bria and Bangui (if Component 2: The cash transfer program of the PACAD provides timely and regular cash transfers (CT) to selected and Bangassou and Bangassou security situation permits) households for a two-year period. They serve as a relief to vulnerable households in areas affected by forced displacement so as to fill immediate consumption gaps and prevent negative coping strategies such as sell/loss Sources: World Bank 2017; Fialho Lopes 2017; Fialho Lopes 2018; Fialho Lopes 2018a, Fialho Lopes 2018b, Fialho Lopes 2019, Auffret 2020a and Auffret 2020b; and World Bank 2020. of assets. With the additional financing in 2020, the CT program is expanding compared to initial plan (AF of US$12 million for component 2), by scaling up coverage to include communities affected by crisis, including COVID-19 and flooding, in addition to forced displacement. The project duration has also been extended until June 2023 (instead of 2021 according to the initial project). A2.3. LONDO description The additional financing also aims at reinforcing project coordination, monitoring and evaluation, and building LONDO provides temporary employment to vulnerable household through a large public lottery system for all the basis for an SSN system (AF of $4 million for component 3). individuals ages 18 years old and more. Beneficiaries are offered a 40-day work contract, at the subsistence wage of CFAF 1,500 per day (approximately US$3). They also receive a bike as a way to join the worksite, which they In addition to CT, the PACAD provided additional benefits to the following populations (over 2017–20): (i) 44,356 can keep after successful completion of the 40 days of work. Women’s participation in the LIPWs is encouraged person-days of employment have been created, (ii) 92,020 people were provided with improved urban living through project communications, but there is no formal quota of female beneficiaries. As of June 2019, 34 percent conditions, and (iii) 2,067 individuals have participated in consultation activities. of beneficiaries were women. With the COVID-19 pandemic, LIPW activities have been suspended and resources under the project have been TABLE A2.2. MAIN FEATURES AND BENEFICIARIES OF PACAD refocused on two activities: (1) production of non-surgical masks to distribute to population, which created employment for 328 sewing workshops—10 million masks were produced and 10,752 tailors and their assistants Regions Bambari, Kaga Bandoro, Paoua and Bangassou employed, for a total of 741,496 worked days (person days); (2) construction of boreholes in the suburbs of Bangui (Bégoua and Bimbo II), which allow access to clean water for an estimated 45,000 beneficiaries. Financing agency World Bank The project is under the leadership of MEPC and is financed by a World Bank grant. The ministry delegated project Responsible agency (borrower) MEPC implementation through a service agreement with the CAR Agency for the Execution of Works of Public Interest. Implementation agency Ministry of Humanitarian Action and National Reconciliation, with UNOPS contracted as Since 2020, the implementation has been directly executed by the LONDO+ Project Implementation Unit. service provided Targeting Vulnerability and Community TABLE A2.2. MAIN FEATURES AND SPENDING OF LONDO Type of transfer In Cash (+ expected transition to mobile payments) Regions National (present in the 71 sous-prefectures) Benefit level CT of CFAF 25,000 per household per quarter (this level of transfer is approximately 10–15 Financing agency World Bank percent of the food consumption level of a household of five people)175 Responsible agency (borrower) Under the leadership of the Minister of Economy, Planning and Cooperation Coverage 2020: 77,880 individuals (15,576 households) Implementation agency CAR Agency for the Execution of Works of Public Interest (AGETIP-CAF) (until 2020, then with Spending 2020: CFAF 845 million the LONDO+ Project Implementation Unit) Gender equity 63% of female beneficiaries Targeting Lottery Starting year 2017 Type of transfer 40 days of work at CFAF 1,500/day (equivalent to US$3) Coverage In 2020: 38,000 LIPW beneficiaries in 70 districts and maintained 2,296.04 km of roads (1,499,194 person-days). Thus, the total numbers of beneficiaries over 2016–20. COVID response: 3,349 beneficiaries were remunerated to produce the non-medical masks, 175  Under the AF, a COVID response CT is also planned. Due to their emergency nature, the crisis-response CTs (for COVID-19 and floods) would and 544,203 non-medical masks were manufactured consist of four quarterly payments of CFAF 25,000 to protect their food security and assets. The crisis-response CTs would be available only to those who do not already benefit from the PACAD standard CT in order to spread benefits. The total number of expected beneficiaries is 188 estimated at 30,000 households, corresponding to 150,000 individuals. 189 FIGURE A3.1. DIFFERENT TYPE OF CAPITAL HEALTH SPENDING Regions National (present in the 71 sous-prefectures) Spending on benefits 2020 spending on stipends: CFAF 2,450 million 2020 spending on bikes: CFAF 2,470 million 2018 68.3 13.1 15.9 Total: 0.07 percent of GDP 2017 56.1 30.2 Year Gender equity 36 percent of female beneficiaries in 2018, 34 in 2019, and 38 in 2020 2016 15 85 Starting year 2016 2015 100 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% LONDO spending, 2016–20 Share in % Share of Infrastructures on Total Capital Health Expenditures 2016 2017 2018 2019 2020 Share of Medical Equipment on Total Capital Health Expenditures Share of Transport Equipment on Total Capital Health Expenditures Cumulative spending* on LIPW (CFAF thousand) 504,583 1,100,872 1,464,565 1,750,978 2,248,791 Share of ICT equipment on Total Capital Health Expenditures Share of Other non Classified Machine and Equipment on Total Capital Health Expenditures Yearly spending increase** (CFAF thousand) 504,583 596,289 363,693 286,413 497,812 Source: Own compilation based on Bance 2016, 2017, 2018; Fraiji 2020a,b, 2021; and Grumelard 2019. Source: Author computations using the 2015–2018 NHA. * Including investment expenditure in tools and equipment, management, and administrative cost as well as the spending on salaries and the cost of bikes. **The month of reporting varies per years (June in 2016, 2017, and 2020 and March in 2018 and 2019); hence the yearly increases do not necessarily represent 12 months’ increase. Box A 3.1. The uneven distribution of health workers in CAR A3. HEALTH Region 4, with 13 percent of the population, has the highest rate of under-five mortality in the country (2 times more than in Bangui); a stunting rate of 39.6 percent (18.6 percentage points higher than in Bangui); twice as many health facilities per 10,000 inhabitants as Bangui, including 79 total functional health TABLE A3.1. DISTRIBUTION OF HEALTH FACILITIES BY FUNCTIONALITY STATUS AND HEALTH posts (the second largest after Region 3 and roughly 8.7 times more than Bangui); 7 functional hospitals REGIONS FROM THE LATEST WHO HERAMS/SURVEY (3 more than in Bangui); and 49 functional health centers (5 more than Bangui). Region 4 only has 1 health professional per 10,000 inhabitants as compared to 31 health professionals per 10,000 inhabitants in Central Districts Regional Secondary Health Health Bangui. Region 6, with 12 percent of the population, has the second highest stunting rate in the country hospitals hospitals hospitals hospitals centers posts TOTAL (43.1 percent, roughly 2 times more than in Bangui); the second-highest under-five mortality rate in the country of 108.2 per 1,000 live births (1.8 times higher than in Bangui); twice the total number of health Heath regions F1 NF2 F NF F NF F NF F NF F NF F NF TOTAL facilities per 10,000 inhabitants as Bangui, including 57 total function health posts (roughly 6 times more than Bangui), 9 functional hospitals (5 more than Bangui), and 61 functional health centers (17 more Health region 1 1 0 5 0 0 0 4 0 80 3 58 16 148 19 167 than Bangui). Region 6 only has 1 health professional per 10,000 inhabitants as compared to 31 health Health region 2 0 0 5 0 1 0 2 0 72 3 56 13 136 16 152 professionals per 10,000 inhabitants in Bangui. Health region 3 0 0 7 0 1 0 1 0 53 8 129 37 191 45 236 FIGURE A3.2. TREND IN KEY HEALTH OUTCOMES INDICATORS IN CAR Health region 4 0 0 3 0 1 0 3 0 47 2 79 20 133 22 155 Health region 5 0 0 2 0 1 0 2 0 19 1 47 5 71 6 77 90 80 Health region 6 0 0 5 0 1 0 3 0 51 10 57 41 117 51 168 70 60 Health region 7 4 0 0 0 0 0 0 0 44 7 9 0 57 7 64 Percent % 50 Total 5 0 27 0 5 0 15 0 366 34 435 132 853 166 1019 40 30 Source: 2019 SARA/HeRAMS Survey (this is from the SARA/HeRAMS Survey sample covering 98 percent of total health facilities in the country). 20 *1 F: Functional *1 NF: Non Functional 10 0 1994-1995 2000 2006 2010 2019 Year Stunting Antenatal care (at least one visit) Birth attended by skilled staff Sources: WDI and CAR 2018 MICS survey. 190 191 TABLE A3.2. TOTAL GENERAL HEALTH EXPENDITURES BY FINANCING SOURCES TABLE A3.3. CURRENT HEALTH EXPENDITURES BY FUNDING SOURCES IN CAR WITH RELEVANT (TREND 2012–18) COMPARATOR COUNTRIES government health government health per capita (in $ USD international PPP)a Donor spending (% international PPP) international PPP) international PPP) Other Domestic Private Out-of-pocket per Other domestic private expenditure per capita Domestic general Domestic general Out-of-pocket (% of current health of current health of current health expenditure per Donor spending Other domestic Other domestic capita (in $ USD capita (in $ USD expenditure (% health spending per Total current health spending (% of current health Donor spending per private health private health government health government health health spending (% capita (in US$ Donor spending (% spending per expenditure) expenditure) expenditure) expenditure) Out-of-pocket per Domestic general Domestic general Out-of-pocket (% expenditures per of current health of current health of current health of current health expenditure (% capita (in US$) capita (in US$) capita (in US$) (in 2018) capita (in US$ expenditure) expenditure) expenditure) expenditure) Indicators (in US$) Burundi 20.4 30.9 16.2 24.6 16.8 25.6 12.4 18.9 Cameroon 11.4 8.5 8.0 6.0 101.0 75.6 13.2 9.9 2012 5.5 27.0 3.5 17.2 11.2 54.7 0.2 1.1 20.5 CAR 49.8 51.4 6.1 6.3 40.4 41.7 0.7 0.7 2013 6.1 34.1 3.6 20.1 8.1 44.8 0.2 1.0 18 Chad 12.4 15.6 13.4 17.0 48.9 61.9 4.3 5.5 Congo 10.0 7.9 46.1 36.8 65.6 52.3 3.8 3.0 2014 7.2 34.5 3.0 14.5 10.4 50.2 0.2 0.9 20.8 Ethiopia 23.9 35.9 15.6 23.4 23.6 35.5 3.5 5.2 2015 7.9 41.4 1.7 9.1 9.3 48.8 0.1 0.8 19.0 Guinea 10.8 9.9 18.0 16.4 66.2 60.6 14.3 13.1 2016 7.2 32.8 2.4 11.0 12.1 55.2 0.2 1.0 21.9 Kenya 27.8 15.5 75.5 42.1 42.3 23.6 33.6 18.7 Sierra Leone 66.6 25.9 25.0 9.7 115.2 44.8 50.5 19.6 2017 9.4 31.5 3.3 10.9 16.9 56.4 0.4 1.2 30 Liberia 3,187.9 b 25.2 3,180.7 25.2 5,283.1 41.8 991.1 7.8 2018 27.6 51.4 3.4 6.3 22.4 41.7 0.4 0.7 53.7 Mali 32.4 36.0 25.4 28.2 30.5 33.9 1.7 1.9 Mozambique 74.1 62.9 24.9 21.2 11.4 9.7 7.3 6.2 Percentage 249% 24% 100% -31% 141% -15% 300% -13% 183% change (base Niger 9.2 11.8 25.9 33.2 38.0 48.8 4.9 6.2 year 2015) Burkina Faso 17.0 15.2 47.5 42.5 40.0 35.8 7.2 6.5 Sudan 22.3 7.6 66.9 22.8 194.1 66.2 9.7 3.3 FIGURE A3.3. BREAKDOWN OF CAPITAL HEALTH EXPENDITURES BY FINANCING SOURCES SSAc 104.3 22.1 206.3 31.9 202.6 36.6 57.1 9.3 SSA excluding Liberia 37.2 22.1 141.7 32.1 92.2 36.5 36.8 9.4 SSA excluding Liberia 37.0 21.4 144.7 32.6 93.3 36.4 37.6 9.6 and CAR 2018 3% 97% FCV 143.4 24.1 194.7 31.8 239.3 39.0 43.4 5.1 FCVd (Excluding 48.21 24.05 101.36 32.01 81.69 38.92 13.77 5.03 2017 25% 75% Liberia) FCVe (Excluding 48.15 23.16 104.44 32.84 83.02 38.83 14.19 5.17 Liberia and CAR) 2016 0% 100% CEMAC 17.6 14.5 83.3 24.1 149.0 55.0 20.5 6.4 CEMAC (excluding 11.2 7.1 98.7 27.6 170.7 57.6 24.5 7.6 2015 0% 100% CAR) LICf 150.0 29.9 141.6 21.8 244.7 41.1 45.5 7.2 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% LIC (excluding Liberia 32.5 29.2 25.5 22.3 51.3 41.1 9.5 7.4 Capital Health Expenditure from Domestic Public funding (the government) and CAR) Capital Health Expenditure from External donors funding a. A PPP exchange rate is the number of units of a country’s currency required to buy the same amount of goods and services in the domestic Capital Health Expenditure from Domestic Private sources including OOPs market as the U.S. dollars would buy in the United States. b. Such high values are attributed to the $ PPP exchange rate which has been the lowest in Liberia in 2018 with 1 international dollar equal to only 0.5 Liberian dollars and with a US$ to Liberian dollars exchange rate equivalent to 144.0 implying that the US Current international dollars Source: Author computations using the WHO GED database. in Liberia should be multiplied by 278.32 to get the PPP International $ amount equivalent. c. 47 countries as per the WHO. d. For a total of 33 countries, excluding West Bank and Gaza territory and Kosovo whose data doesn’t exist in the WHO GED database and also excluding 4 FCV countries with missing data across our core indicators in the dataset namely Libya, Somalia, Syria and Yemen in lieu of the 39 FCV countries listed here: https://pubdocs.worldbank.org/en/888211594267968803/FCSList-FY21.pdf. e. For a total of 33 countries, excluding West Bank and Gaza territory and Kosovo whose data doesn’t exist in the WHO GED database and also excluding 4 FCV countries with missing data across our core indicators in the dataset namely Libya, Somalia, Syria and Yemen in lieu of the 39 FCV countries listed here: https://pubdocs.worldbank.org/en/888211594267968803/FCSList-FY21.pdf. f. Using the 2018 Income group classification. 192 193 TABLE A3.4. CAPITAL HEALTH EXPENDITURES BY FINANCING SOURCES IN CAR FIGURE A3.4. YEARLY CONTRIBUTION OF MULTILATERAL DONORS ON TOTAL MULTILATERAL FUNDING IN CAR (government) % of capital domestic private sources (% of total capital health domestic public sources expenditures funded by expenditures funded by expenditures per capita (in $ PPP international) out-of-pocket sources sources (government) (in US$ millions PPP)  expenditures funded expenditures funded expenditures funded health expenditures) (in US$ millions PPP) (in US$ millions PPP) international $ PPP) 70.0% by domestic private (% of capital health Share on total multilateral health funding funded by external donors (in millions by domestic public by external donors 60% sources including 60.0% expenditures) expenditures) Capital health Capital health Capital health Capital health Capital health Capital health Capital health Capital health expenditures expenditures 50.0% 39% 37% 40.0% 34% 31.4% 31.4% 30.0% 24% 16% 20.0% 15% Cameroon 404.08 16.02 NA NA NA NA NA NA 14% 11.7% 10.2% 6.6% 9% 9% 8% 5.1% 10.0% 3.6% 5% 4% 4% 4% 3% 3% 3% CAR 8.3 1.8 8.0 97 0.3 3 0 0 2% 1% 1% 1% 1% 1% 1% 0.0% 2015 2016 2017 2018 Congo, Rep. 24.0 4.6 NA NA NA NA NA NA Year EU GAVI Global Funds World Bank (IDA+IBRD) UNAIDS UNDP UNFPA UNICEF WFP WHO Other Multilateral donors Niger 113.18 5.04 46.00 41 52.6 46 14.6 13 Burkina Faso 156.3 7.9 8.6 5 140.0 90 7.7 5 OVERVIEW OF BILATERAL DONORS IN CAR 70% 63% Share on total bilateral health funding SSAa 212.5 20.2 103.6 48.7 69.1 32.5 39.8 18.7 55% 60% (excluding 50% CAR) 41% 35% 34% 40% FCVb 105.9 4.5 30.7 29 67.4 63.6 7.8 7.4 24% 30% 22% 22% 21% 20% (excluding 19% 16% 20% CAR) 10% 10% 5% 4% 4% 2% Source: Author computations using the 2018 WHO GED database. 0% a. Here only 6 countries had data available on Capital Health Expenditures broken down by financing sources. 2015 2016 Year 2017 2018 b. Here only 3 countries had data available on Capital Health Expenditures broken down by financing sources. Belgium Canada France Germany Japan Luxembourg The Netherlands Spain Switzerland US (USAID) Apostolic Nuncio Other Bilateral donors Source: Author computations using the 2015–2018 NHA. Box A3.2. Landscape of external financing in CAR From 2015 to 2018, The Global Funds had one of the highest contributions of total multilateral funding, followed by the World Bank, the UNDP, WHO, UNICEF, and GAVI. The share of bilateral funding on total TABLE A3.5. BREAKDOWN OF CURRENT HEALTH EXPENDITURES BY HEALTH CARE FUNCTIONS external health financing in CAR increased by 16 percentage points, from 39 percent of total external financing in 2017 to 55 percent in 2018. Between 2015 and 2017, the Netherlands was the main bilateral administration current health current health current health current health current health health system Medical goods expenditures) expenditures) expenditures) expenditures) expenditures) and financing care (share of curative care curative care donors in CAR with over 35 percent of total bilateral funding in the health sector, followed by the United Governance, Outpatient Preventive Inpatient States (USAID) and Switzerland (share of (share of (share of (share of CAR 5% 48% 1% 37% 8% Congo 32% 17% 26% 7% 15% Ethiopia 5% 43% 1% 30% 10% Guinea 6% 14% 44% 18% 10% Kenya 22% 40% 3% 16% 18% Liberia 4% 32% 11% 11% 19% Mali 12% 42% 9% 30% 7% Mozambique 6% 30% 0% 29% 23% Niger 20% 19% 29% 14% 14% Burkina Faso 15% 34% 18% 20% 10% 194 195 TABLE A3.6. LEVEL AND SHARE OF REPRODUCTIVE HEALTH ON CURRENT HEALTH FIGURE A3.5. UNDER FIVE YEARS OLD MORTALITY RATE PER REGIONS AND SHARE ON EXPENDITURES CURRENT HEALTH EXPENDITURES Maternal conditions, Contraceptive management Other reproductive health and TOTAL Category2: reproductive in CFAF millions (family planning), in CFAF millions contraceptive, in CFAF millions health, in CFAF millions 59.5498 RS7 45.5 2015 1,519.99 128.13 5066.86 6,714.98 RS6 6.4 3% 0.3% 10% 13% RS5 2016 1,945.81 160.29 6501.85 8,607.94 122.5708 RS4 8 3% 0.3% 11% 15% RS3 2017 2,872.48 374.66 9412.50 12,659.64 RS2 4% 0.5% 12% 16% 2018 7,230.47 1046.01 18707.89 26,984.36 RS1 5% 1% 13% 19% 0 20 40 60 80 100 120 140 U5 Mortality Share of budget on health Source: Authors’ computations using the WHO GED. Note: The percentage in italic represents the share in current health expenditures. TABLE A3.7. LEVEL AND SHARE OF MISCELLANEOUS HEALTH CONDITIONS ON CURRENT FIGURE A3.6. TREND OF CURRENT HEALTH EXPENDITURES BY GENDER HEALTH EXPENDITURES Category 3: nutritional Category 4: noncommunicable Category 5: injuries, Category 6: other and unspecified deficiencies, in CFAF millions diseases (NCDs), in CFAF millions in CFAF millions diseases and conditions, in CFAF millions 100.00 35.00 90.00 2015 3,443.46 2,605.39 0 684.73 34.50 93.40 34.50 80.00 Amount in CFAF billions 7% 5% 0% 1% 70.00 34.10 34.00 Share in % 60.00 2016 2,531.19 4,053.71 0 812.08 33.70 50.00 33.50 53.20 4% 7% 0% 1% 40.00 45.80 38.80 33.00 30.00 32.90 33.10 2017 5,485.49 5,564.12 0 1,240.83 20.00 27.10 32.50 17.40 20.10 10.00 7% 7% 0% 2% 0.00 32.00 2015 2016 2017 2018 2018 6,385.41 8,629.90 0 2,100.85 Year Women CHE Men CHE MenCHE % (Total CHE) 5% 6% 0% 2% Source: Author computations using the 2015–2018 NHA. Note: The percentage in italic represents the share on current health expenditures. Source: Author computations using the 2018 NHA, CAR. TABLE A3.8. BREAKDOWN/CATEGORIZATION OF TOTAL (CURRENT) HEALTH EXPENDITURES FIGURE A3.7. CURRENT HEALTH EXPENDITURES ON CHILDREN UNDER FIVE BY SOURCES OF BY REGIONS FUNDING IN VOLUME   2015 2016 2017 2018 Health Amount in CFAF % Amount in CFAF % Amount in CFAF % Amount in CFAF % 160000.0 139,161 Regions billions billions billions billions 140000.0 Amount in CFAF millions RS1 4.8 9.6 7.7 13.0 8.8 10.9 13.1 9.4 120000.0 100000.0 80,206.55 RS2 3.7 7.3 6.6 11.3 9.2 11.5 14.0 10.1 80000.0 58,877.98 63,837.7 RS3 6.8 13.5 8.7 14.8 8.8 11.0 20.2 14.5 60000.0 32,410.1 RS4 3.1 6.2 5.4 9.1 7.5 9.4 11.2 8.0 40000.0 21,223.6 31538.9 28110.0 17731.1 20000.0 12689.6 10690.9 RS5 1.1 2.2 1.5 2.5 1.6 2.0 8.5 6.1 2901.8 5632.2 3988.1 4188.8 0.0 RS6 3.0 5.9 4.2 7.1 4.1 5.2 8.9 6.4 2016 2017 2018 Domestic GGE in the less than 5 years old External source of funding in the less than 5 years old RS7 27.9 55.3 24.8 42.2 40.1 50.1 63.4 45.5 Domestic Private expennditure in the less than 5 years old Current health expenditure on under 5 years old Current Health Expenditure Total 50.5 100 58.9 100 80.2 100 139.2 100 Source: Author computations using the 2015–2018 NHA. Source: Author computations using the WHO GED. 196 197 FIGURE A3.8. CURRENT HEALTH EXPENDITURES ON CHILDREN UNDER FIVE BY SOURCES OF TABLE A3.9. CURRENT HEALTH EXPENDITURES ON CHILDREN UNDER FIVE IN CAR AND FUNDING IN VOLUME (%) RELEVANT COMPARATORS Domestic private health expenditure to U5 years expenditure to U5 years expenditure (in US$) on of general government old PPP $ international 70% U5 years old as a share U5 years old expenses U5 years old expenses as a % current health Health expenditures 60% old per capita PPP $ government health government health 60% per capita (in US$) international PPP  U5 years old PPP $ 55% Domestic general Domestic general as a % of the GDP expenditures to 49% External donor to U5 years old 50% Stunting rate expenditures international international revenues (%) 46% 40% 40% 44% 36% 30% 33% Indicators 27% (as of 2018*) 20% 10% 14% 12% 7% CAR 44.5 2.0 5.0 45.9 2.9 22.0 19.6 40.8 0% 2016 2017 2018 Niger 41.6 3.8 3.9 53.4 11.7 5.4 24.5 48.5 Domestic GGE in the less than 5 years old as a % of less than 5 years old health expenditure External source of funding in the less than 5 years old as a % of less than 5 years old health expenditure Mali 28.1 1.0 1.2 31.2 4.8 15.4 7.9 26.9 Domestic Private expennditure in the less than 5 years old as a % of less than 5 years old health expenditure Current HE on under five years old as a % of Current Health Expenditure Benin 28.0 0.7 0.8 33.7 4.0 9.4 14.6 32.2 Source: Author computations using the WHO GED. Guinea 34.0 1.3 1.2 31.1 5.8 3.1 25.0 30.3 Source: Author computations using the WHO GED. * Latest year in the current WHO GED. TABLE A3.10. BREAKDOWN OF CURRENT HEALTH EXPENDITURES BY FINANCIAL SCHEMES Compulsory financing arrangements as % of current health Compulsory Voluntary expenditure including health financing (I) government financing insurance (II) arrangement (III) (IV) Other unspecified financing schemes including social health insurance and Government financing arrangements Compulsory financing arrangements Compulsory private health insurance compulsory private health insurance as % of current health expenditure as % of current health expenditure Voluntary financing arrangements as % of current health expenditure as % of current health expenditure (including social health insurance and compulsory health insurance Rest of the world as % of current including government financing Compulsory health insurance as % of current health expenditure Voluntary health care payment Social health insurance as % of and compulsory private health (n.e.c.) as % of current health current health expenditure including OOP payments TOTAL (I)+(II)+(III)+(IV) health expenditure OOP payments expenditure insurance) (in %) 2012 24.29 24.29 0 0 0 75.70 21.0 54.7 0 0 100 2013 28.51 28.51 0 0 0 71.5 26.6 44.9 0 0 100 2014 24.49 24.49 0 0 0 75.50 25.3 50.2 0 0 100 2015 22.25 22.25 0 0 0 77.75 28.97 48.78 0 0 100 2016 25.98 25.98 0 0 0 74.01 18.81 55.21 0 0 100 2017 15.58 15.58 0 0 0 84.42 28.01 56.42 0 0 100 2018 13.41 13.41 0 0 0 86.59 44.91 41.67 0 0 100 Source: Author computations using the 2018 WHO GED. 198 199 TABLE A3.11. TREND OF DOMESTIC GOVERNMENT HEALTH FINANCING, 2012–18 FIGURE A3.9. TREND IN OOP PAYMENTS IN CAR AND SSA Domestic general Domestic general Domestic government health spending government health government health (% general government spending) 70 % of OOP on Current Household Indicators expenditure (% of GDP) expenditure per capita in PPP (priority to health) (%) 60 2012 0.6 3.5 4.3 50 Expenditures 40 2013 0.9 3.6 7.1 30 2014 0.7 3.0 3.9 20 10 2015 0.5 1.7 3.3 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2016 0.6 2.4 5.0 Year 2017 0.7 3.3 5.3 CAR SSA (IDA & IBRD countries) 2018 0.7 3.4 4.2 Source: Author using data from the 2018 WHO GED and WDI. Average 7-year increase-CAR 0.1 -3% -0.1 (in pp/ absolute difference) (base 2012) TABLE A3.13. PROJECTED GHE PER CAPITA UNTIL 2026 UNDER THE STATUS QUO SCENARIO 1 Average 4-year increase-CAR 0.2 100% 0.97 Average yearly (in pp/ absolute difference) (base Projected variable 2020 2021 2022 2023 2024 2025 2026 growth rate 2015) GHE/GGE (Priority to health) 5.16 5.16 5.16 5.16 5.16 5.16 5.16 0% 4-year increase - LIC (base 2015) 0.0 9% 0.3 GHE/ GDP 24.3 19.3 18.6 18.6 18.8 19.0 18.7 -4.27% 4-year increase - FCV (base 2015) 0.15 11% 0.01 4-year increase - SSA (base 2015) 0.0 13% 0.3 Projected GDP per capita in current 489.9 552.3 590.8 624.6 659.1 694.3 729.9 6.87% US$ 4-year increase - CEMAC -0.1 0% 0.9 (base 2015) Projected GHE per capita in CFA Franc 3524.0 2918.1 2977.3 3139.1 3346.1 3556.8 3671.3 0.7% Source: Author computation using the 2018 WHO GED. Projected GHE per capita in current 6.13 5.50 5.68 6.00 6.41 6.81 7.03 2.3% US$ in CAR TABLE A3.12. EXECUTED GOVERNMENT/PUBLIC SPENDING BY THE MINISTRY OF HEALTH, Projected GHE per capita in US$ PPP 10.34 12.26 10.08 10.26 10.79 11.46 12.12 2.7% 2012–20  in CAR Projected GHE per capita in current 61.59 60.32 59.96 60.20 61.30 62.72 64.56 0.78% 2012 2013 2014 2015 2016 2017 2018 2019 2020 US$ PPP in SSA Current GDP (in CFAF billions) 1,281.6 835.5 935.6 1,002.6 1,081.5 1,203.3 1,266.0 1,359.9 1,360.0 Source: Author using data from the 2018 WHO GED and WDI Total actual government budget (CFAF 106.5 80.7 54.3 97.3 104.7 182.4 167.5 164.7 215.4 billions) TABLE A3.14. PROJECTED GHE PER CAPITA UNTIL 2026 UNDER PRO-HEALTH SCENARIO 2 Total executed budget for the health sector 6.4 6.9 4.8 5.5 4.9 8.0 8.2 10.3 20.6 (CFAF billions) Average yearly Projected variable 2020 2021 2022 2023 2024 2025 2026 growth rate Total executed health budget as share of 6.0% 8.6% 8.8% 5.6% 4.7% 4.4% 4.9% 6.2% 9.6% total executed government budget (%) Projected GHE per capita in 4.4% 5.26 5.5 5.7 6.0 6.2 6.5 6.8 current US$ in CAR Executed health budget as share of GDP (%) 0.5% 0.8% 0.5% 0.5% 0.5% 0.7% 0.6% 0.8% 1.5% Yearly percentage change previous years_ _ 8.7% -31.0% 14.4% -9.9% 63.8% 1.9% 25.0% 101.1% Projected GHE per capita in 4.40% 6.40 6.68 6.98 7.28 7.60 7.94 8.29 Actual Government health Budget (%) current US$ in CAR in PPP Yearly percentage change previous years_ _ -34.8% 12.0% 7.2% 7.9% 11.3% 5.2% 7.4% 0.0% Projected GHE per capita in 6.75% 236.1 252.1 269.1 287.2 306.6 327.3 349.4 Currrent GDP Per Capita (%) current US$ in SSA in PPP Yearly percentage change previous years_ _ -24.2% -32.8% 79.2% 7.7% 74.2% -8.2% -1.7% 30.8% Source: Author using data from the 2018 WHO GED and WDI. Total Government Budget (%) Source: Author computations using data from the Ministry of Finance and IMF WEO (for the GDP). 200 201 FIGURE A3.10. PROJECTED TREND IN OOP PAYMENTS PER CAPITA UNDER SCENARIO 2 TABLE A3.17. SALARY AND ALLOWANCES OF MEDICAL DOCTORS IN 2020 BY DISTRICTS (PREFECTURES) 60.0 21.00 Average Gross salary Average Family Average Average Years of 50.0 20.50 OOP payments in $ Prefectures (In CFA Franc) Allowances Indemnites experience Expenditures in $ 20.72 20.50 20.03 19.77 19.51 19.24 18.95 40.0 20.27 20.00 BAMINGUI-BANGORAN 3 1 3 3 30.0 19.50 305,193.3 5000 175,822.7 1.67 20.0 19.00 10.0 18.50 BANGUI 111 25 111 111 0.0 18.00 319,808.1 5500 173,084.3 6.73 2019 2020 2021 2022 2023 2024 2025 2026 External Otherprivate GHE OOP OOPs BASSE-KOTTO 5 3 5 5 315,052 9166.667 177,768 1 Source: Author using data from the 2018 WHO GED and WDI. HAUT-MBOMOU 4 0 4 4 TABLE A3.15. PROJECTED GHE PER CAPITA IN 2026 UNDER PROCYCLICAL SCENARIO 3 312,725 . 179,921 2.25 Projected variable 2020 2021 2022 2023 2024 2025 2026 HAUTE-KOTTO 5 1 5 5 Projected GHE per capita in current US$ in CAR 3.18 2.95 2.80 2.68 2.55 2.41 2.28 308,244 10,000 170,380 6.4 Projected GHE per capita in current US$ in CAR in PPP 6.03 5.71 5.21 4.69 4.17 3.64 3.12 KEMO 2 2 2 2 Projected GHE per capita in current US$ in SSA in PPP 170.1 176.5 185.4 194.8 204.2 213.9 223.3 336,090 7500 190,686 2 Source: Author using data from the 2018 WHO GED and WDI. LOBAYE 8 2 8 8 TABLE A3.16. COMPARATIVE ANALYSIS OF THE WAGE BILL 321,066.3 7,500 185,112.3 3.4 MAMBERE-KADEI 8 3 8 8 2017  2018  2019  2020  340,714.8 10833.33 184,672.3 7.75 Total Public Wage bill  57400.4  58966.8  63747.0  68565.7  GDP ( Current in Billions CFA Franc)  1203.32  1265.64  1333.99  1371.89  MBOMOU 6 2 6 6 % GDP  4.8%  4.7%  4.8%  5.0%  327,282.3 12500 178,377.7 3.66 Total Public Emloyees (Number)  26 372  26 843  27 654  31 035  NANA-GRIBIZI 2 0 2 2 Average monthly wage bill per employee in (CFA Franc)   181380.4  183060.7  192097  184108.4  322,725 . 189,921 2.5 Health Wage Bill  NANA-MAMBERE 3 2 3 3 % of total public wage bill   5.7%  5.7%  5.5%  5.1%  340,833.3 12500 191,196 3 in Millions CFA Franc  3292.7  3366.2  3479.0  3499.9  OMBELLA MPOKO 12 4 12 12 Health Workers   324,833.7 7500 178,275.7 4.66 Number  1882  1907  1873  1833  OUAKA 5 4 5 5 % total public employees  7.1%  7.1%  6.8%  5.9%  319,628 5000 171,604 7 Average monthly wage bill per employee in (CFA Franc)   145 799.3  147 099.9  154 786.7  159 113.2  OUHAM 16 5 16 16 Education Workers  326,683.8 5000 184,527 4.06 % of total public wage bill   21.30%  21.10%  19.40%  18.30%  OUHAM-PENDE 6 4 6 6 Number  6908  6863  6551  6506  334,295 6875 190,107.7 3.16 % total public employees  26.20%  25.60%  23.70%  21%  VAKAGA 1 1 1 1 National Defense  341,090 12500 190,686 3 % of total public wage bill   29.0%  29.6%  32.9%  33.9%  Source: Ministry of public service Number  9350  9051  10176  12368  % total public employees  35.45%  33.72%  36.80%  39.85%  Average monthly wage bill per employee in (CFA Franc)   148364.6  160708  171597.3  156457.9  Source: Ministry of public service 202 203 TABLE A3.18. GROSS SALARIES OF DIFFERENT CATEGORIES OF HEALTH WORKERS Box A3.3. Additional financing is required to meet the latest health Investment Case’s (IC) targets Assistant Nurse Assistant caregiver Nurse/Midwife Medical Doctor/ Generalist In the health sector, financing needs and sustainability analyses are based on the latest Investment Case Total number of workers 233 62 324 207 validated by the CAR government in 2019 and currently being updated by the Global Financial Facility with 2017 the latest 2018/2019 MICS data released early 2021. Average gross salary 2017 90,984.65 145,816.7 91,636.43 351,784.2 CAR has some of the highest maternal, neonatal, child mortality, and adolescent fertility rates in Sub- (in CFA Franc) Saharan Africa. The 2019 IC, which mainly relied on the 2010 MICS data, focuses on improving maternal mortality, neonatal mortality, under-five years old mortality, stunting, and adolescent fertility rates with Total number of workers 253 108 318 244 different targets set for 2022 through a range of high-impact RMNCAH interventions. More specifically, 2018 the 2019 IC aims at reducing: Average gross salary 2018 90,394.2 134,392.3 95,096.4 333,721.1 • maternal mortality ratio from 882 per 100,000 livebirths (in 2015, now 829 per 100,000 livebirths) to (in CFA Franc) 593 per 100,000 livebirths by 2022; Total number of workers 246 96 298 203 • neonatal mortality from 46 per 1,000 livebirths (in 2010, now 28 per 1,000 livebirths) to 29 per 1,000 2019 livebirths by 2022; • under 5 child mortality rate from 150 per 1,000 livebirths (in 2010, now 99 per 1,000 livebirths) to 90 Average gross salary 2019 90,962.92 133,365.8 98,278.64 331,610.4 per 1,000 livebirths by 2022; (in CFA Franc) • under 5 child stunting rate from 40.7 percent (in 2010, now 39.8 percent) to 31 percent by 2022; and • adolescent fertility rate from 229 per 1,000 women aged 15–19 (in 2010, now 184 births per 1,000) to Total number of workers 205 146 283 216 90 per 1,000 women by 2022. 2020 The set of RMNCAH interventions in the IC targets women of reproductive age (15–49 years), pregnant Average gross salary 2020 92,891.24 108,936.5 100,807.6 338,475.5 women, infants, and children under the age of 5 years. These interventions will help prevent the deaths of (in CFA Franc) 513 mothers, 3,050 newborns, and 6,832 children under 5 years in three priority areas of the country—for a total of more than 10,395 lives saved by 2022. Source: Ministry of public service A Global Financing Facility (GFF) resource mapping undertaken in 2019 estimated that achieving the TABLE A3.19. TREND OF CHWS IN CAR IC by 2022 will require a total funding of US$150,621,801 for the 2020–22 period. The government’s total financial engagement is estimated at US$8,020,668 (6 percent of total funding requirements) and 2016 2019 2021 contributions from other key external partners are estimated at US$86,492,696, with the World Bank/GFF Total Needs (12 percent of total funding requirements) and the EU (21 percent of total funding requirements) being CHW 2016/ CHW 2019/ CHW 2021/ of CHWs as of Gaps of CHWs the major donors. Thus, the funding gap is estimated at US$56,108,438.179 Detailed analyses are available CHW2016 1000 hbts CHW 2019 1000 hbts CHW2021178 1000 hbts 2021176 as of 2021177 in the technical health background paper. Region 1 463 0.6 582 0.7 630 0.7 848 218 To improve health services delivery in underserved areas of the country and address the shortage of health professionals in regions outside of Bangui, the government should recruit more CHWs in the Region 2 612 0.7 690 0.7 1020 1.0 983 -37 regions most in need. Based on recent estimates from the Ministry of Health, there is a total of 5,070 CHWs in CAR, equivalent to roughly 1 CHW per 1,000 inhabitants. One of the most immediate priority Region 3 554 0.5 1003 0.9 1020 0.9 1124 104 actions the government should undertake is filling the gaps of CHWs in regions with poorer health outcomes and with the lowest share of CHWs per capita. The three health regions with less than 1 CHW Region 4 558 0.8 655 0.9 900 1.2 721 -179 per 1,000 inhabitants are region 7 (Bangui and suburbs) with 0.2 per 1,000 inhabitants, region 3 (0.9 per 1,000 inhabitants), and region 1 (0.7 per 1,000 inhabitants). The latter two regions should be the focus. Region 5 272 1.1 350 1.4 360 1.4 261 -99 Bangui, considered the region with the best health outcomes with the lowest under five mortality rate (59.5 per 1000 live births), already has 30.9 health professionals per 10,000 inhabitants, well beyond the Region 6 555 0.9 657 1.0 900 1.4 662 -238 WHO threshold of 23. The government will need to recruit 218 CHWs in region 1 (with the fourth highest Region 7 70 0.1 227 0.2 240 0.2 971 731 mortality rate of the country of 101.48 per 1,000 live births) and 104 CHWs in region 3 (with the third highest mortality rate of the country of 105.10 per 1,000 live births). TOTAL 3084 0.6 4164 0.8 5070 0.9 5571 501 To achieve this, assuming one CHW has a monthly remuneration of CFAF 25,000 CFA180 (~US$45), the Source: WHO 2017 & 2019 SARA surveys and 2021 MOH/ UNICEF estimates 179  These are conservative estimates and must be interpreted with caution. The World Bank Global Financial Facility (GFF) is currently conducting series of workshops with the government to update the 2022 IC using the recent 2018/2019 MICS data released earlier this year. The updated IC was scheduled to be finalized end of July 2021 but was postponed and is now scheduled to be released by the end of October 2021. 180  The monthly financial or nonfinancial compensation of CHWs in CAR was found to substantially vary between CFAF 10,000 (~US$18) to 176  Assuming 1 CHWs should cover 1000 Inhabitants CFAF 75,000 (~US$135) for the same package of services offered and working time. However, the current proposal made by the Ministry of 177  Difference between CHWs needed and those already existing on the ground Health under the CHW draft strategy supported by UNICEF is CFAF 25,000 (~US$45). The current variability of CHWs’ remuneration hinders the 204 178  These are estimates shared by MOH as part of UNICEF ongoing work on the CHW strategy in CAR sustainability of activities and the delivery of basic health services. 205 total costs for a year181 is an estimated CFAF 97 million (US$174,300) (excluding Bangui182), equivalent to TABLE A3.21. DISTRIBUTION OF GOVERNMENT HEALTH EXPENDITURES BY HEALTH CARE 0.2 percent of the current total allocated budget for health in 2020.183 This is roughly 11 times the current SERVICE PROVIDERS FROM 2015 TO 2018 IN MILLIONS CFA FRANC budget allocated to CHWs in CAR, which has remained constant at CFAF 8,500,000184 (approximately US$15,522 or only 0.034 percent of the allocated budget for health the same year). At 0.2 percent of the 2015 2016 2017 2018 health sector budget, CAR’s increased CHW expenditures will still be lower than the CHW health budget share in comparable countries, namely Burkina Faso (1.56 percent) and Sierra Leone (16.5 percent). The FCFA Franc FCFA Franc FCFA Franc FCFA Franc 2016‑2018 2015‑2018 In billions In billions In billions In billions current amount (if disbursed by the government) should help cover at least the costs of remuneration for Average Average CHWs, hence tapping into the main incentive driving their motivation to deliver quality health services. (in %) (in %) Healthcare providers %  %  %  %  Currently, management committees (COGES) at the health facility level contribute to the remuneration of CHWs, but COGES funding is insufficient. Most CHW interventions come from donors and technical Hospitals 2404  21.4%  3952  25.8%  4513  36.1%  4822  25.8%  27%  29%  partners, resulting in the lack of sustainability of interventions and strategies. With the support of UNICEF, the government is currently finalizing the 2022–2026 Community Health Worker Strategy with Ambulatory health care 557  5.0%  606  4.0%  591  4.7%  533  2.9%  4%  4%  a detailed costing. The preliminary estimates presented above could serve as initial guidance in the providers strategy’s finalization. Anxillary health services 55  0.5%  60  0.4%  74  0.6%  53  0.3%  0%  0%  providers Retailers and others 0  0.0%  0 0.0%  0 0.0%  0 0.0%  0%  0%  providers of medical goods  TABLE A3.20. DISTRIBUTION OF TOTAL CURRENT HEALTH EXPENDITURES BY HEALTH CARE Providers of preventive 4670  41.6%  2841  18.6%  421  3.4%  643  3.4%  17%  8%  SERVICE PROVIDERS FROM 2015 TO 2018 IN FCFA (ALL SOURCES COMBINED) healthcare Providers of 3546  31.6%  6407  41.9%  5174  41.4%  11215  60.1%  44%  48%  2015 2016 2017 2018 administrative and Average 2016- financing services of the Average 2015- health care system 2018 (in %) FCFA Franc FCFA Franc FCFA Franc FCFA Franc 2018 (in %) In billions In billions In billions In billions Rest of the World  0  0.0%  1432  9.4%  1723  13.8%  1400  7.5%  7.7%  10.2%  Healthcare providers %  %  %  %  Source: 2015-2018 National Health Account Hospitals 12.59  24.90  19.7  33.5  23.66  29.5  29.01  20.8  27.2  27.9  Ambulatory health care 15.23  30.20  20.24  34.4  30.08  37.5  47.35  34  34.0  35.3  providers Anxillary health services 0.22  0.40  0.4  0.7  0.69  0.9  0.13  0.1  0.5  0.6  providers Retailers and others 0.56  1.10  0.75  1.3  1.02  1.3  1.65  1.2  1.2  1.3  providers of medical goods  Providers of preventive 12.71  25.20  9.96  16.9  14.61  18.2  48.34  34.7  23.8  23.3  healthcare Providers of administrative 9.16  18.20  6.41  10.9  8.42  10.5  11.21  8.1  11.9  9.8  and financing services of the health care system Rest of the World  0  0  1.43  2.4  1.72  2.1  1.45  1  1.4  1.8  Source: 2015-2018 National Health Account 181  These are only remuneration costs that do not include training, equipment, and supervision costs. 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