Abstract
BackgroundUser 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.MethodsSixteen 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.ResultsFourteen (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).ConclusionsOur 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.
Highlights
User fees have been shown to constitute a major barrier to the utilisation of health-care, in low-income countries such as the Democratic Republic of Congo (DRC)
User fee subsidisation – whereby the running cost of services is subsidised by a donor and/or government resulting in a lower fee to the user - may be an expedient approach towards achieving such abolition, for vulnerable groups
This study aimed to address this gap by answering the following research question: what are the effects on healthcare utilisation of a policy to subsidise user fees in the DRC? Specific objectives included assessing the short-and long-term effects of user fee subsidisation on health-care utilisation in a) individual health zones and b) for the entire sample population
Summary
User fees have been shown to constitute a major barrier to the utilisation of health-care, in low-income countries such as the Democratic Republic of Congo (DRC). Such barriers can lead to the exclusion of vulnerable individuals from health-care. Ponsar et al [5] showed that user fees in several African countries may present significant barriers for accessing health-care and can result in the exclusion of vulnerable individuals They suggested a mechanism of user fee abolition combined with compensation of health facilities for the lost revenue. Utilisation of health services is extremely low; on average one person consults health services every 6.7 years [19]
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