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.'
affiliation: 'Maini, R (Corresponding Author), Dept Int Dev, 83 Ave Roi Baudouin,
  Kinshasa, DEM REP CONGO.

  Maini, Rishma; Carter, Daniel, Dept Int Dev, 83 Ave Roi Baudouin, Kinshasa, DEM
  REP CONGO.

  Van den Bergh, Rafael; Tayler-Smith, Katie; Zachariah, Rony, Med Sans Frontieres
  Operat Ctr Brussels, Operat Res Unit LuxOR, Luxembourg, Luxembourg.

  van Griensven, Johan, Inst Trop Med, B-2000 Antwerp, Belgium.

  Ousley, Janet; Ho, Lara, Int Rescue Comm, Kinshasa, DEM REP CONGO.

  Mhatre, Seb, Dept Int Dev, London, England.'
article-number: '504'
author: Maini, Rishma and Van den Bergh, Rafael and van Griensven, Johan and Tayler-Smith,
  Katie and Ousley, Janet and Carter, Daniel and Mhatre, Seb and Ho, Lara and Zachariah,
  Rony
author-email: mainirishma@gmail.com
author_list:
- family: Maini
  given: Rishma
- family: Van den Bergh
  given: Rafael
- family: van Griensven
  given: Johan
- family: Tayler-Smith
  given: Katie
- family: Ousley
  given: Janet
- family: Carter
  given: Daniel
- family: Mhatre
  given: Seb
- family: Ho
  given: Lara
- family: Zachariah
  given: Rony
da: '2023-09-28'
doi: 10.1186/s12913-014-0504-6
files: []
issn: 1472-6963
journal: BMC HEALTH SERVICES RESEARCH
keywords: 'User fees; Subsidisation; Health-care utilisation; Operational research;

  DRC'
keywords-plus: FINANCIAL BARRIERS; SERVICES
language: English
month: NOV 5
number-of-cited-references: '23'
orcid-numbers: 'Van den Bergh, Rafael/0000-0001-6277-8713

  Maini, Rishma/0000-0002-0835-6154

  zachariah, rony/0000-0002-2915-9328'
papis_id: a0de866a34a65e72534a6b1e4c26b3a2
ref: Maini2014pickingbill
times-cited: '12'
title: 'Picking up the bill - improving health-care utilisation in the Democratic
  Republic of Congo through user fee subsidisation: a before and after study'
type: article
unique-id: WOS:000348416100001
usage-count-last-180-days: '0'
usage-count-since-2013: '0'
volume: '14'
web-of-science-categories: Health Care Sciences \& Services
year: '2014'