title: Picking up the bill - improving health-care utilisation in the Democratic Republic of Congo through user fee subsidisation: a before and after study.
abstract: BACKGROUND
  User 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.
  
  
  METHODS
  Sixteen 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.
  
  
  RESULTS
  Fourteen (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).
  
  
  CONCLUSIONS
  Our 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.
authors.forename: Rishma
authors.initials: R
authors.lastname: Maini
authors.forename: Rafael
authors.initials: R
authors.lastname: Van den Bergh
authors.forename: Johan
authors.initials: J
authors.lastname: van Griensven
authors.forename: Katie
authors.initials: K
authors.lastname: Tayler-Smith
authors.forename: Janet
authors.initials: J
authors.lastname: Ousley
authors.forename: Daniel
authors.initials: D
authors.lastname: Carter
authors.forename: Seb
authors.initials: S
authors.lastname: Mhatre
authors.forename: Lara
authors.initials: L
authors.lastname: Ho
authors.forename: Rony
authors.initials: R
authors.lastname: Zachariah
mesh_terms: D015023:Democratic Republic of the Congo; D003906:Developing Countries; D005249:Fees and Charges; D006291:Health Policy; D006296:Health Services / Q000191:economics* / Q000706:statistics & numerical data*; D006297:Health Services Accessibility; D006801:Humans; D065186:Interrupted Time Series Analysis; D010342:Patient Acceptance of Health Care