Free Care Policy Research Articles

Barriers and facilitators to healthcare facility utilization by non-Ebola patients during the 2018–2020 Ebola outbreak in the Democratic Republic of Congo

BackgroundAn Ebola Virus Disease (EVD) outbreak occurred in North Kivu between 2018 and 2020. This eastern province of the Democratic Republic of Congo was also grappling with insecurity caused by several armed groups. This study aimed to explore the barriers and facilitators to utilizing Healthcare Facilities (HCFs) by non-Ebola patients during the crisis.MethodsA qualitative case study was conducted in Beni and Butembo with 24 relatives of 15 deceased non-EVD patients, 47 key informants from healthcare workers (HCWs), as well as community leaders. Semi-structured interviews were conducted to explore three key areas: (i) the participants’ illness history, care pathway, care, and social support; (ii) their perceptions of how EVD affected the care outcome; and (iii) their opinions on the preparedness, supply, use, and quality of healthcare before and during the outbreak. All interviews were recorded, transcribed verbatim, and thematically analysed using Atlas-ti 8.0.ResultsNine of the 15 deaths were female and their ages ranged from 7 to 79 years. The causes of death were non-communicable (13) or infectious (2) diseases. Conspiracy theories, failure to establish security, and the concept of the ''Ebola business'' were associated with misinformation and lower levels of trust in government and HCFs. The negative perceptions, fear of being identified as an Ebola case, apprehension about the triage unit, and inadequacy of personal protective equipment resulted in a preference for private or informal HCFs. For half of the deceased’s relatives, the Ebola outbreak hastened their death. Conversely, community involvement, employing familiar, neutral, and credible HCWs, and implementing a free care policy increased the number of visits. These results were observable despite a lack of funds, overstretched HCWs, and long waiting time.ConclusionsOur findings can inform policies before and during future outbreaks to enhance the resilience of routine HCFs by maintaining dialogue between HCWs and patients, and rebuilding confidence in HCFs. Quantitative studies including context analysis are essential to identify the determinants of care-seeking during such a crisis.

Impact of a free care policy on routine health service volumes during a protracted Ebola virus disease outbreak in the Democratic Republic of Congo

BackgroundIn response to the DRC's 10th Ebola Virus Disease (EVD) outbreak, the government subsidized routine health services in select health zones with the goal of maintaining routine service volumes. We assess the impact of the initial and revised Free Care Policies (FCP) on total clinic visits, uncomplicated malaria, simple pneumonia, fourth antenatal care clinic visits, and measles vaccinations, testing the hypothesis that routine services would not significantly decrease during the FCP. Methods and findingsWe used data from the DRC's national health information system spanning January 2017 to November 2020. Intervention facilities were those that were initially and secondarily enrolled in the FCP, which occurred in August 2018 and November 2018, respectively. Comparison facilities were limited to the North Kivu Province and were from health zones that recorded at least one case of Ebola. A controlled interrupted time series analysis was conducted. The FCP appeared to have a positive effect in increasing overall clinic attendance rates, uncomplicated malaria case rates, and simple pneumonia case rates in those health zones where the policy was enacted relative to comparison sites. The longer-term effects of the FCP were mostly non-significant or, if significant, relatively modest in nature. Rates for measles vaccinations and fourth ANC clinic visits appeared to be unaffected or minimally affected, respectively, by the implementation of the FCP and relative to comparison sites. We did not observe the decrease in measles vaccinations that has been observed elsewhere. The study is limited in that we were unable to account for health facility bypassing and service volumes at private health facilities. ConclusionsOur findings provide evidence that FCPs can be used to maintain routine service provision during outbreaks. Additionally, the study design demonstrates that routinely reported health information from the DRC are sensitive enough to detect changes in health policy.

Assessing routine health information system performance during the tenth outbreak of Ebola virus disease (2018-2020) in the Democratic Republic of the Congo: A qualitative study in North Kivu.

The Democratic Republic of Congo has implemented reforms to its national routine health information system (RHIS) to improve timeliness, completeness, and use of quality data. However, outbreaks can undermine efforts to strengthen it. We assessed the functioning of the RHIS during the 2018-2020 outbreak of Ebola Virus Disease (EVD) to identify opportunities for future development. We conducted a qualitative study in North Kivu, from March to May 2020. Semi-structured interviews were conducted with 34 key informants purposively selected from among the personnel involved in the production of RHIS data. The topics discussed included RHIS functioning, tools, compilation, validation, quality, sharing, and the use of data. Audio recordings were transcribed verbatim and thematic analysis was used to study the interviewees' lived experience. The RHIS retained its structure, tools, and flow during the outbreak. The need for other types of data to inform the EVD response created other parallel systems to the RHIS. This included data from Ebola treatment centers, vaccination against Ebola, points of entry surveillance, and safe and dignified burial. The informants indicated that the availability of weekly surveillance data had improved, while timeliness and quality of monthly RHIS reporting declined. The compilation of data was late and validation meetings were irregular. The upsurge of patients following the implementation of the free care policy, the departure of healthcare workers for better-paid jobs, and the high prioritization of the outbreak response over routine activities led to RHIS disruptions. Delays in decision-making were one of the consequences of the decline in data timeliness. Adequate allocation of human resources, equitable salary policy, coordination, and integration of the response with local structures are necessary to ensure optimal functioning of the RHIS during an outbreak. Future research should assess the scale of data quality changes during outbreaks.

Maternal perceptions of the quality of Care in the Free Maternal Care Policy in sub-Sahara Africa: a systematic scoping review

BackgroundThe world aims to achieve universal health coverage by removing all forms of financial barriers to improve access to healthcare as well as reduce maternal and child deaths by 2030. Although free maternal healthcare has been embraced as a major intervention towards this course in some countries in sub-Saharan Africa (SSA), the perception of the quality of healthcare may influence utilization and maternal health outcomes. We systematically mapped literature and described the evidence on maternal perceptions of the quality of care under the free care financing policies in SSA.MethodsWe employed the Arskey and O’Malley’s framework to guide this scoping review. We searched without date limitations to 19th May 2019 for relevant published articles in PubMed, Google Scholar, Web of Science, Science Direct, and CINAHL using a combination of keywords, Boolean terms, and medical subject headings. We included primary studies that involved pregnant/post-natal mothers, free maternal care policy, quality of care, and was conduct in an SSA country. Two reviewers independently screened the articles at the abstract and full-text screening guided by inclusion and exclusion criteria. All relevant data were extracted and organized into themes and a summary of the results reported narratively. The recent version of the mixed methods appraisal tool was used to assess the methodological quality of the included studies.ResultsOut of 390 studies, 13 were identified to have evidence of free maternal healthcare and client perceived quality of care. All the 13 studies were conducted in 7 different countries. We found three studies each from Ghana and Kenya, two each in Burkina Faso and Nigeria, and a study each from Niger, Sierra Leone, and Tanzania. Of the 13 included studies, eight reported that pregnant women perceived the quality of care under the free maternal healthcare policy to be poor. The following reasons accounted for the poor perception of service quality: long waiting time, ill-attitudes of providers, inadequate supply of essential drugs and lack of potable water, unequal distribution of skilled birth attendants, out-of-pocket payment and weak patient complaint system.ConclusionThis study suggests few papers exist that looked at maternal perceptions of the quality of care in the free care policy in SSA. Considering the influence mothers perceptions of the quality of care can have on future health service utilisation, further studies at the household, community, and health facility levels are needed to help unearth and address all hidden quality of care challenges and improve maternal health services towards attaining the sustainable development goals on maternal and child health.

Effect of a free healthcare policy on health services utilisation for non‐malarial febrile illness by children under five years in Burkina Faso: an interrupted time series analysis

To assess the effect of a free healthcare policy for children under five years old implemented in Burkina Faso since April 2016, on the use of health care of non-malarial febrile illnesses (NMFI). To assess the immediate and long-term effect of the free healthcare policy in place, we conducted an interrupted time series analysis of routinely collected data on febrile illnesses from three urban primary health centres of Ouagadougou between 1 January 2015 and 31 December 2016. Of the 39046 febrile cases reported in the study period, 17017 NMFI were included in the study. Compared to the period before the intervention, we observed an immediate, non-statistically significant increase of 7% in the number of NMFI (IRR=1.07; 95% CI=0.75, 1.51). Compared to the trend that would have been expected in absence of the intervention, the results showed a small but sustained increase of 6% in the trend of monthly number of NMFI during the intervention period (IRR=1.06; 95%CI=1.01, 1.12). Our study highlighted an increase in the uptake of healthcare services, specifically for NMFI by children under five years of age, after the implementation of a free care policy. This analysis contributes to informing decision makers on the need to strengthen the capacities of healthcare centres and to anticipate the challenges of the sustainability of this policy.

Impact of a free care policy on the utilisation of health services during an Ebola outbreak in the Democratic Republic of Congo: an interrupted time-series analysis

BackgroundDuring past outbreaks of Ebola virus disease (EVD) and other infectious diseases, health service utilisation declined among the general public, delaying health seeking behaviour and affecting population health. From May...

Effect of a prospective payment method for health facilities on direct medical expenditures in a low-resource setting: a paired pre-post study.

Almost all sub-Saharan countries have adopted cost-reduction policies to facilitate access to health care. However, several studies underline the reimbursement delays experienced by health facilities, which lead to deficient implementation of these policies. In April 2016, for its free care policy, Burkina Faso shifted from fee-for-service (FFS) paid retrospectively to FFS paid prospectively. This study tested the hypothesis that this new method of payment would be associated with an increase in direct medical expenditures (expenses covered by the policies) associated with deliveries. This paired pre-post study used data from two cross-sectional national surveys. Observations were paired according to the health facility and the type of delivery. We used a combined approach (state and household perspectives) to capture all direct medical expenses (delivery fees, drugs and supplies costs, paraclinical exam costs and hospitalization fees). A Wilcoxon signed-rank test was used to test the hypothesis that the 2016 distribution of direct medical expenditures was greater than that for 2014. A total of 279 pairs of normal deliveries, 66 dystocia deliveries and 48 caesareans were analysed. The direct medical expenditure medians were USD 4.97 [interquartile range (IQR): 4.30–6.02], 22.10 [IQR: 15.59–29.32] and 103.58 [IQR: 85.13–113.88] in 2014 vs USD 5.55 [IQR: 4.55–6.88], 23.90 [IQR: 17.55–48.81] and 141.54 [IQR: 104.10–172.02] in 2016 for normal, dystocia and caesarean deliveries, respectively. Except for dystocia (P = 0.128) and medical centres (P = 0.240), the 2016 direct medical expenditures were higher than the 2014 expenses, regardless of the type of delivery and level of care. The 2016 expenditures were higher than the 2014 expenditures, regardless of the components considered. In the context of cost-reduction policies in sub-Saharan countries, greater attention must be paid to the provider payment method and cost-control measures because these elements may generate an increase in medical expenditures, which threatens the sustainability of these policies.

Impact of a Free Health Care Policy in the Democratic Republic of the Congo During an Ebola Outbreak: An Interrupted Time-Series Analysis

Background: During past outbreaks of Ebola Virus Disease (EVD) and other infectious diseases, health service utilization declined among the general public, delaying health seeking behavior and affecting population health. In 2018, the Democratic Republic of Congo (DRC) announced a free health care policy during an EVD outbreak in affected and neighboring areas. We evaluated the impact of this policy on health service utilization. Methods: Using monthly data from the national Health Management Information System from January 2017 to January 2019, we examined rates of the use of nine health services at primary health facilities: total visits; first and fourth antenatal care visits; institutional deliveries; postnatal care visits; DTP vaccinations; and visits for uncomplicated malaria, pneumonia, and diarrhea. We used controlled interrupted time series analysis with a mixed effects model to estimate changes in the rates of services use during the policy (June -September 2018) and afterward. Findings: Use of most services increased, including EVD affected zones. Total visits and visits for pneumonia and diarrhea increased more than two-fold relative to the control areas (p<0·001), while institutional deliveries and first antenatal care increased between 20-50% (p<0·01). Visits for DTP, fourth antenatal care visits and postnatal care visits were not significantly affected. Most increases did not persist after the policy ended. Interpretation: The free care policy was effective at rapidly increasing the use of health services, but this effect was not sustained post-FCP. Such policies may mitigate the impact of infectious disease outbreaks on health service utilization. Funding Statement: This project received funding from the Rapid Research Fund for Ebola supported by the International Development Research Centre, Social Sciences and Humanities Research Council, and Canadian Institutes of Health Research, and AXA Research Fund. Dr. Law received salary support through a Canada Research Chair and a Michael Smith Foundation for Health Research Scholar Award. Dr. Grepin also received salary support through a Canada Research Chair. Declaration of Interests: Dr. Law has consulted for Health Canada, the Health Employees’ Union, the Conference Board of Canada, and provided expert witness testimony for the Attorney General of Canada. All other authors report no potential conflicts of interest. Ethics Approval Statement: The research protocol was approved by the Ethics Committees at Wilfrid Laurier University and Kinshasa School of Public Health.

Impact of Risk and Organizational Factors in Niger Cesarean Practice

Objectives: The aim of this work is to examine the effects of the free care policy on the access, management and practice of cesarean section in Niger. The secondary data collected from the various health facilities as well as the national health information system made it possible to analyze the impact of the risk and organizational factors on the practice of cesarean section in Niger before and after this policy. Methods: A panel analysis was conducted with the same data to determine the impact of this policy on the evolution of these factors and the likelihood of delivery by cesarean section in Niger. In these models, the need for Caesarean is justified by the existence of a medical matrix of gravity and a matrix of explanatory variables of organizational order. Two different models are estimated. The first explains the practice of cesarean section in Niger with data collected from all regions of the country. The second explains Caesarean section practice in the three regions that have a national maternity reference. The data collected covers the period 2006-2014. A total of 2,250 files were studied in the eight regions of the country. Results: When considering only the period after free care, the results obtained indicate that the risk factors were less important in explaining the occurrence of a caesarean section than before. This is valid for both the medical severity variables and the organizational variables. Discussion: These results confirm those of the statistical analysis in which the national rate of caesarean section has been observed to be changing, slowing down and declining. Thus, alongside the policy of care for pregnant women and cesarean section, the State must also make efforts to improve the health card, the proper functioning of the care system to through the timely reimbursement of factors issued and the availability of human resources in quantity and quality to hope to achieve the objectives pursued through this policy.

Nepal’s Free Health Care Policy in Practice: Perspectives from Community Stakeholders, Providers and Users of Health Services in Myagdi District

Government of Nepal has introduced Free Health Care Policy (FHCP) through different tiers of health delivery system in 2007. With the objective of understanding the perspectives of community stakeholders, health service providers, and the services users towards free care policy, a qualitative-quantitative study was conducted in selected communities of Myagdi district from December 2010 to January 2011. Although the majority of user group thought that free care service is good but only two-third of them had received free care. Shortage of free essential drugs at health facility centers, absence of health workers and lack of clear information about free services or counseling on free services available at health facility centers are the most repeated issues raised by the service users. Similarly, the service providers had similar experiences and perceptions on FHCP. The majority of the community stakeholders also had positive perception on this implemented policy. They have observed that many facilities had shortage of drugs and people are not having free health care. Many health facilities lacked interaction on FHCP, and service users did not have equitable access to the services provided. Overall, though the free care was perceived to be good policy, its satisfactory implementation remains one of the challenges. Many of the areas relating to service delivery need to be strengthened. A reliable supply system of drugs and its regular monitoring mechanism can ensure the effective implementation of free health care services.

‘We are bitter but we are satisfied’: nurses as street-level bureaucrats in South Africa

This study investigates how a group of nurses based in busy urban primary care health clinics experienced the implementation of the free care (the removal of fees) and other South African national health policies introduced after 1996. The study aimed to capture the perceptions and perspectives of front-line providers (street-level bureaucrats) concerning the process of policy implementation. Using qualitative and quantitative research methods, the study paid particular attention to the personal and professional consequences of the free care policy; the factors which influence nurses’ responses to policy changes such as free care; and what they perceive to be barriers to effective policy implementation. The research reveals firstly that nurses’ views and values inform their implementation of health policy; secondly that nurses feel excluded from the process of policy change; and finally that social, financial and human resources are insufficiently incorporated into the policy implementation process. The study recommends that the practice of policy change be viewed through the lens of the ‘street-level bureaucrat’ and highlights three sets of related managerial actions.

Examination of attendance patterns before and after introduction of south africa's policy of free health care for children aged under 6 years and pregnant women

President Nelson Mandela's first major policy announcement after election was that all health care for children under 6 years and for pregnant and lactating women would be free in the...