Picking up the bill - improving health-care utilisation in the Democratic Republic of Congo through user fee subsidisation: a before and after study

BMC Health Services Research

Rony Zachariah³  Lara Ho¹  Seb Mhatre⁵  Daniel Carter⁴  Janet Ousley¹  Katie Tayler-Smith³  Johan van Griensven²  Rafael Van den Bergh³  Rishma Maini⁴ 

[1] International Rescue Committee, Kinshasa, the Democratic Republic of Congo;Institute of Tropical Medicine, Antwerp, Belgium;Médecins Sans Frontières Operational Centre Brussels, Operational Research Unit (LuxOR), Luxembourg, Luxembourg;Department for International Development, British Embassy, 83 Ave Roi Baudouin, Kinshasa, the Democratic Republic of Congo;Department for International Development, London, UK

关键词: DRC;    Operational research;    Health-care utilisation;    Subsidisation;    User fees;   

Others  :  1092348
DOI  :  10.1186/s12913-014-0504-6

 received in 2013-07-06, accepted in 2014-10-06,  发布年份 2014

【 摘 要 】

Background

User fees have been shown to constitute a major barrier to the utilisation of health-care, particularly in low-income countries such as the Democratic Republic of Congo (DRC). Importantly, such barriers can lead to the exclusion of vulnerable individuals from health-care. In 2008, a donor-funded primary health-care programme began implementing user fee subsidisation in 20 health zones of the DRC. In this study, we quantified the short and long-term effects of this policy on health-care utilisation.

Methods

Sixteen health zones were included for analysis. Using routinely collected health-care utilisation data before and after policy implementation, interrupted time series regression was applied to quantify the temporal impact of the user fee policy in the studied health zones. Payment of salary supplements to health-care workers and provision of free drugs - the other components of the programme - were controlled for where possible.

Results

Fourteen (88%) health zones showed an immediate positive effect in health-care utilisation rates (overall median increase of 19%, interquartile range 11 to 43) one month after the policy was introduced, and the effect was significant in seven zones (P <0.05). This initial effect was sustained or increased at 24 months in five health zones but was only significant in one health zone at P <0.05. Utilisation reduced over time in the remaining health zones (overall median increase of 4%, interquartile range −10 to 33). The modelled mean health-care utilisation rate initially increased significantly from 43 consultations/1000 population to 51 consultations/1000 population during the first month following implementation (P <0.01). However, the on-going effect was not significant (P =0.69).

Conclusions

Our research brings mixed findings on the effectiveness of user fee subsidisation as a strategy to increase the utilisation of services. Future work should focus on feasibility issues associated with the removal or reduction of user fees and how to sustain its effects on utilisation in the longer term.

【 授权许可】

   
2014 Maini et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

【 参考文献 】

• [1][http:/ / www.healthfinancingafrica.org/ 3/ post/ 2013/ 04/ a-history-of-the-bamako-initiative- 12-under-the-leadership-of-mr-grant -and-dr-mahler.html] webcite Harmonisation for Health in Africa Blogs..
• [2]Garner P: The Bamako Initiative: financing health in Africa by selling drugs. BMJ 1989, 299:277-278.
• [3][www.stanford.edu/~pdupas/Dupas_Pricing&UserFees.pdf] webcite Dupas P: Global Health Systems: Pricing and User Fees..
• [4][http://www.imf.org/external/np/exr/facts/mdri.htm] webcite International Monetary Fund..
• [5]Ponsar F, Tayler-Smith K, Philips M, Gerard S, Van Herp M, Reid T, Zachariah R: No cash, no care: how user fees endanger health – lessons learnt regarding financial barriers to health-care services in Burundi, Sierra Leone, Democratic Republic of Congo, Chad, Haiti and Mali. Int Health 2011, 3:91-100.
• [6]Lagarde M, Palmer N: The impact of user fees on access to health services in low- and middle-income countries. Cochrane Database Syst Rev 2011., 4
• [7]Lagarde M, Barroy H, Palmer N: Assessing the effects of removing user fees in Zambia and Niger. J Health Serv Res Policy 2012, 17(1):30-36.
• [8]Campbell J, Oulton J, McPake B, Buchan J: Removing user fees? Engage the health workforce. Lancet 2009, 374:1966.
• [9]McPake B, Witter S, Ensor T, Fustukian S, Newlands D, Martineau T, Chirwa Y: Removing financial barriers to access reproductive maternal and newborn health services: the challenges and policy implications for human resources for health. Hum Resour Health 2013, 11:46. BioMed Central Full Text
• [10]Burnham GM, Pariyo G, Galiwango E, Wabire-Mangen F: Discontinuation of cost sharing in Uganda. Bull World Health Organ 2004, 82:187-195.
• [11]Gilson L, McIntyre D: Removing user fees for primary care in Africa: the need for careful action. BMJ 2005, 331:762-765.
• [12]Nabyongo Orem J, Mugisha F, Kirunga C, Macq J, Criel B: Abolition of user fees: the Uganda paradox. Health Policy Plan 2011, 26:41-51.
• [13]James CD, Hanon K, McPake B, Balabanova D, Gwatkin D, Hopwood I, Kirunga C, Knippenberg C, Meessen B, Morris SS, Preker A, Soutevrand Y, Tibouti A, Villeneuve P, Xu K: To retain or remove user fees? Reflections on the current debate in low- and middle- income countries. Appl Health Econ Health Policy 2006, 5(3):137-153.
• [14][http://www.healthsystems2020.org/section/where_we_work/drc/nha] webcite National Health Accounts DRC (2008–2009) Health Systems 20/20..
• [15][http://data.worldbank.org/indicator/NY.GNP.PCAP.CD] webcite World Development Indicators Online..
• [16][http://iresearch.worldbank.org/PovcalNet/povcalSvy.html] webcite World Bank PovCalNet..
• [17]Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Murray CJ: Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010, 375(9726):1609-1627.
• [18]Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, Jha P, Campbell H, Walker CF, Cibulskis R, Eisele T, Liu L, Mathers C: Child health epidemiology reference group of WHO and UNICEF: global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet 2010, 375(9730):1969-1987.
• [19]Document de Stratégie de la Croissance et de la Réduction de Pauvreté. Government of the Democratic Republic of Congo, Kinshasa; 2006.
• [20]Document de Stratégie de Renforcement du Système de Santé. Government of the Democratic Republic of Congo, Kinshasa; 2006.
• [21][http://projects.dfid.gov.uk/projects/GB-1-105861] webcite DFID Access to health-care in the Democratic Republic of Congo (2008–2013)..
• [22]Turner T: The Congo Wars: Conflict, Myth, and Reality. Zed Books, New York; 2007.
• [23][http:/ / rtkapend.wordpress.com/ 2012/ 02/ 17/ drc-population-by-age-group-latest- census-1984] webcite 1984 Latest census in DRC..
• [24][http://web.worldbank.org/] webcite The World Bank: Democratic Republic of Congo..
• [25]Lagarde M: How to do (or not to do)…Assessing the impact of a policy change with routine longitudinal data. Health Policy Plan 2011, 27(1):1-8.
• [26]Dzakpasu S, Powell-Jackson T, Campbell OMR: Impact of user fees on maternal health utilisation and related outcomes: a systematic review. Health Policy Plan 2014, 29(2):137-150.
• [27]Witter S: Health financing in fragile and post-conflict states: what do we know and what are the gaps? Soc Sci Med 2012, 75(12):2370-2377.
• [28]Morena-Serro R, Smith PC: Does progress towards universal health coverage improve population health? Original text. Lancet 2012, 380(9845):917-923.
• [29]Steinhardt LC, Aman I, Pakzad I, Kumar B, Singh LP, Peters DH: Removing user fees for basic health services: a pilot survey and national roll-out in Afghanistan. Health Policy Plan 2011, 26(Suppl 2):92-103.
• [30]Ponsar F, Herp MV, Zachariah R, Gerard S, Philips M, Jouquet G: Abolishing user fees for children and pregnant women trebled uptake of malaria-related inteventions in Kangaba, Mali. Health Policy Plan 2011, 26:72-83.
• [31][http://projects.dfid.gov.uk/projects/GB-1-202732] webcite DFID Access to Health-Care in the Democratic Republic of Congo (2013–2018)..
• [32]Hercot D, Meesen B, Ridde V, Gilson L: Removing user fees for health services in low-income countries: a multi-country review framework for assessing the process of policy change. Health Policy Plan 2011, 26:5-15.