BackgroundComzmercialization of health care has contributed to widen inequities between the rich and the poor, especially in settings with suboptimal regulatory frameworks of the health sector. Poorly regulated fee-for-service payment systems generate inequity and initiate a vicious circle in which access to quality health care gradually deteriorates. Although the abolition of user fees is high on the international health policy agenda, the sudden removal of user fees may have disrupting effects on the health system and may not be affordable or sustainable in resource-constrained countries, such as the Democratic Republic of Congo.Methods and ResultsBetween 2008 and 2011, the Belgian development aid agency (BTC) launched a set of reforms in the Kisantu district, in the province of Bas Congo, through an action-research process deemed appropriate for the implementation of change within open complex systems such as the Kisantu local health system. Moreover, the entire process contributed to strengthen the stewardship capacity of the Kisantu district management team. The reforms mainly comprised the rationalization of resources and the regulation of health services financing. Flat fees per episode of disease were introduced as an alternative to fee-for-service payments by patients. A financial subsidy from BTC allowed to reduce the height of the flat fees. The provision of the subsidy was made conditional upon a range of measures to rationalize the use of resources.ConclusionsThe results in terms of enhancing people access to quality health care were immediate and substantial. The Kisantu experience demonstrates that a systems approach is essential in addressing complex problems. It provides useful lessons for other districts in the country.

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Background By the end of the third wave of the COVID-19 epidemic (May – October 2021), only 3,130 out of the 57,268 confirmed cases of coronavirus disease 2019 (COVID-19) in the Democratic Republic of Congo (DRC) were reported in Kongo Central. This province, and especially its capital city Matadi has essential trade and exchanges with Kinshasa, the epicenter of the COVID-19 epidemic in DRC. Kinshasa accounted for 60.0% of all cases during the same period. The true burden of COVID-19 in Matadi is likely underestimated. In this study, we aimed to determine the SARS-CoV-2 seroprevalence and associated risk factors after the third wave in Matadi. Methods We conducted a prospective population-based cross-sectional study in October 2021. Consenting participants were interviewed and tested using an ELISA commercial kit. We applied univariable and multivariable analysis to evaluate factors associated with seropositivity and adjusted the seroprevalence for the test kit performance. Results We included 2,210 participants from 489 households. Female participants represented 59.1%. The median age was 27 years (interquartile range 16–45 years). The crude SARS-CoV-2 seroprevalence was 82.3%. Age was identified as the main risk factor as younger age decreased the seropositivity odds. Accounting for clustering at the household level increased the seroprevalence to 83.2%. The seroprevalence increased further to 88.1% (95% CI 86.2–90.1%) after correcting for the laboratory test kit performance. Conclusions The SARS-CoV-2 seroprevalence was very high, contrasting with reported cases. Evidence generated from this population-based survey remains relevant in guiding the local COVID-19 response, especially vaccination strategies.

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