Table 19: Percentage of health sector budget from total expenditure excluding debt Year 2008 2009 2010 2011 Budget 9.33 Source: CPCMB 8.90 7.97 7.34 Average 2008- 2011 8.36 Table 20: Trend of the health sector expenditure compared to the GDP Year 2008 2009 2010 2011 Budget 2.18 Source: CPCMB 1.42 1.43 1.49 Average 2008- 2011 1.63 However, one should note a recovery in investment spending in Health in 2011 after the decline observed in 2009 and 2010. As a percentage of the GDP, the share of health was limited to 1.6% on average between 2008 and 2011. The largest share of spending is devoted to the operations, including the "wages and salaries" component. During the 2008-2011 period, the share of the operation has averaged 67% for the health sector. Moreover, issues of distribution of funds are significant. Budget allocation to different services shows that only (6) general hospitals and administration of the central level alone have consumed over 70% of the budget allocated to the health sector. The decentralised health services through which the MDGs are expected to be reached, only work with the cost recovery system (no budget line for CSS and CSI). Besides the allocation issue, there is also the issue of disbursement. The medium-term expenditure framework (MTEF), which should allow a bottom-up planning is still not functional. Table 21: Distribution of grants to health care providers Providers Public Health Programmes Health Administration General Hospitals Other Hospitals Health Centres Other providers Source: National Health Accounts 2012 2009 14 0 75 3 4 4 2010 24 5 50 6 3 10 Financial accessibility Despite the policies of free services implemented in recent years, affordability remains a significant barrier in accessing health services. According to data from the ECOM in 2011, the cost of services is the main factor of dissatisfaction among the population with regard to health services: 38% of users find them too expensive and the rate reached 49% in rural areas (against 26% in urban areas). The price of services is one of the main reasons given by families who do not go to a health service. 81