Three-Dimensional Fragmentation of Health-Care Purchasing and Universal Health Coverage in the Democratic Republic of the Congo

Progress towards universal health coverage requires available resources to be purchased, allocated, and governed coherently.In the Democratic Republic of the Congo (DRC), analyses of health financing commonly focus on resource scarcity and reliance on out-of-pocket payments, while fragmentation of the purchasing function has received less attention.This analytical review examines fragmentation through three complementary dimensions: financing sources, providerpayment mechanisms, and the institutions that exercise or influence purchasing.A narrative synthesis of health-policy documents, institutional reports, and scientific literature was undertaken and informed by a qualitative comparison of six African country experiences.The analytical framework combines strategic purchasing, neo-institutional theory, and transaction-cost economics.The reviewed literature suggests that compartmentalised financial flows, parallel payment arrangements, and overlapping institutional responsibilities may increase coordination burdens, create unclear incentives for providers, and weaken accountability.The study proposes a three-dimensional model that makes these interactions visible and helps to organise reform options.It concludes that a transition towards more strategic purchasing in the DRC requires clearer purchasing governance, gradual harmonisation of payment arrangements, strengthened information systems, and explicit attention to equity.These priorities should accompany, rather than replace, the necessary expansion of resources for health.