Improving financial access to health care in the Kisantu district in the Democratic Republic of Congo: acting upon complexity

Abstract

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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“…User fees have become the main source of income for healthcare providers, covering healthcare activities and staff remuneration [7]. This situation induced substantial overcharging and over-prescribing of medicines, diagnostic tests, and medical procedures [8].…”

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“…Integrated Health Facilities: Government, religious, or private not-for-profit health facilities that are subject to agreements with the government and are therefore under the authority of the local Health Zone Office (Stasse et al, 2015).…”

“…Non-integrated Health Facilities: Health facilities (often for-profit) that are not subject to any official agreements with the government (Stasse et al, 2015).…”

“…The DRC has a decentralized health zone (HZ)/district system that links primary health care with referral services at three main levels ( and oversees activities within each province; and 3) the peripheral level or the HZ is the basic operational unit for health programs and health service delivery. This level includes the central HZ offices, district hospitals, health centers, and health posts with referral links to provincial and national hospitals (Kalisya et al, 2015;Muyembe et al, 2013;Naughton et al, 2017;Rajan et al, 2014;Stasse et al, 2015;USAID, 2017). health centers/hospitals and at least one referral district hospital, operated by the government, faith-based organizations (FBOs; operate 40% of HZs), and nongovernment organizations (NGOs)-all integrated into the government health system (Barroy et al, 2014;Bertone, Lurton, & Mutombo, 2016;Muyembe et al, 2013;Rajan et al, 2014;USAID, 2017).…”