Abstract
BackgroundIn the Democratic Republic of the Congo (DRC), more than 93% of users must pay out of pocket for care. Despite the risk of catastrophic expenditures (CE), 94% of births in Lubumbashi are attended by skilled personnel. We aimed to identify risk factors for CE associated with obstetric and neonatal care in this setting, to document coping mechanisms employed by households to pay the price of care, and to identify consequences of CE on households.MethodsWe used mixed methods and conducted both a cross-sectional study and a phenomenological study of women who delivered at 92 health care facilities in all 11 health zones of Lubumbashi. In April and May 2015 we followed 1,627 women and collected data on their health care and household expenses to determine whether they experienced CE, defined as payments that reached or exceeded 40% of a household’s capacity to pay. Two months after discharge, we conducted semi-structured interviews with 58 women at their homes to assess the consequences of CE.ResultsIn all, 261 of 1,627 (16.0%) women experienced CE. Whether a woman or her infant experienced complications was an important contributor to her risk of CE; poverty, younger age, being unmarried, and delivering in a parastatal facility or with more highly trained personnel also increased risk. Among a subset of women with CE interviewed 2 months after discharge, those who were in debt or who had lost their trading income or goods were unable to pay their rent, their children’s school fees, or were obliged to reduce food consumption in the household; some had become victims of mistreatment such as verbal abuse, disputes with in-laws, denial of paternity, abandonment by partners, financial deprivation, even divorce.ConclusionsWe found a higher proportion of CE than previously reported in the DRC or in other urban settings in Africa. We suggest that the government and funders in DRC support initiatives to put in place mutual-aid health risk pools and health insurance and introduce and institutionalize free maternal and infant care. We further suggest that the government ensure decent and regular payment of providers and improve the financing and functioning of health care facilities to improve the quality of care and alleviate the burden on users.
Highlights
In the Democratic Republic of the Congo (DRC), more than 93% of users must pay out of pocket for care
In 2014, in Lubumbashi, we showed that expenses tied to obstetric care were higher when compared to other cities in Africa [16], but information on the incidence of catastrophic expenditures (CE), its determinants and health and socioeconomic consequences among women who deliver with skilled attendance, is lacking
The city is divided into eleven Health Zones (HZ), all but one of which has a General Referral Hospital (GRH); on average, each HZ has 15 Health Centers (HC)
Summary
In the Democratic Republic of the Congo (DRC), more than 93% of users must pay out of pocket for care. The countries that have improved coverage in skilled birth attendance are those that showed great progress toward attaining the target of Millennium Development Goal 5, to improve maternal health [2]. Sustainable Development Goal 3.1–2 is focused on universal coverage of skilled birth attendance to attain a significant reduction in maternal and perinatal mortality by 2030 [1, 4]. Attaining this coverage has become a driving force of maternal health programs around the world [1, 4, 5]. This growth in the number of assisted deliveries brings with it an increase in the burden on the health system —in terms of infrastructure, medications, equipment, and human resources for health [1, 6]— the Every Mother, Every Newborn initiative [4] reaffirms the Abuja accords and insists on the responsibility of governments to allocate at least 15% of their budgets to health care, while encouraging new modes of financing for development in the post-2015 era
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