User fees for health services are government policy in the Democratic Republic of the Congo. The Ministry of Health is clear that user fees are an essential feature of making health services feasible and sustainable. They believe that free health services create dependency and could put health care at risk should donor funding end. Additionally, since free health services generally have a high cost per capita, often they are accessible only to a limited population or geographic area.
While this policy is well-intended and grounded in studies, DRC presents high levels of vulnerable populations unable to afford these fees. In particular, the elderly, disabled and survivors of sexual or gender-based violence often lack the resources to obtain care.
In order to follow national government policy while also increasing geographical coverage, ASSP is promoting a gradual increase in universal access to health care in project areas, as an alternative to unrestricted “free health care.” Through this approach, IMA aims to ensure that health services will be free or adequately subsidized for people in need. The ASSP Project seeks to create a system that decreases barriers to access of care, but effectively motivates staff at all levels and is done in such a way that the intrinsic incentives in the system motivate the government, the community and the individual to accept reasonable responsibility for the cost of health care. In the ASSP system, the majority of the clients pay a modest amount for their health care. A limited number of people are granted partial or full exemptions to have access to care.
The Data Says it All
The number of births attended at a health facility by skilled health personnel has steadily increased since the start of the project.
ASSP strives to ensure the poorest and most vulnerable Congolese can access lifesaving primary health care. ASSP seeks to establish a system that decreases barriers to access to care, but also aligns with the national government’s policy for the individual to assume reasonable responsibility for health care costs. Specific objectives in line with the ASSP’s approach to universal access to health care are:
- Improve mother, newborn and child health in all targeted health zones across all economic, geographic, age and gender cohorts
- Provide treatment to survivors of sexual or gender-based violence, a large population currently without access to services and usually of more vulnerable classifications
- Provide health care to survivors of emergencies, such as war, tribal conflicts and natural catastrophes
- Ensure people with disabilities, orphans, widows, the elderly and anyone lacking social protection receives health care within their means; improve their health indicators, reducing disparities between the most vulnerable and average citizens
Over 3,000 women with fistula received surgery, with a 94% success rate, improving both their health and psycho-social well-being. Most had lived with fistula – ashamed and often isolated from their communities – for more than four years, largely due to barriers in accessing treatment. In addition to the surgery, ASSP provided grants to each woman to facilitate her reintegration into the community.
ASSP has provided over 2,832 survivors of SGBV with post-exposure prophylaxis kits to help protect them from contracting HIV.
ASSP began rolling out annual community scorecards at affiliated health facilities and has reached a coverage of 89% of health areas, surpassing its goal of 80%. Findings showed that many communities felt their health center provided poor customer service and charged high fees compared to low-income levels of the client population. The scorecard program gives a voice to the communities and makes them feel engaged in health facility management. It is also an instrument for improving gender equity within communities and particularly in health care delivery, as sub groups of women and youth are established during the process to ensure their voices are heard and that these voices influence decisions on improvement measures to prioritize.
Enrolled CHE health cooperative groups have generated over $80,000 in subscription income for at least 141 health centers. Revenues grew nearly 370% from Y1 to Y2, improving health facilities’ ability to provide for all clients (including the indigent) and increasing the social safety net for health emergencies.