Impacts of performance-based financing on health system performance: evidence from the Democratic Republic of Congo.

BACKGROUND: Health systems' weakness remains one of the primary obstacles towards achieving universal access to quality healthcare in low-income settings. Performance-based financing (PBF) programs have been increasingly used to increase access to quality care in LMICs. However, evidence on the impacts of these programs remains fragmented and inconclusive. We analyze the health system impacts of the PBF program in the Democratic Republic of the Congo (DRC), one of the largest such programs introduced in LMICs to date. METHODS: We used a health systems perspective to analyze the benefits of PBF relative to unconditional financing of health facilities. Fifty-eight health zones in six provinces were randomly assigned to either a control group (28 zones) in which facilities received unconditional transfers or to a PBF program (30 zones) that started at the end of 2016. Follow-up data collection took place in 2021-2022 and included health facility assessments, health worker interviews, direct observations of consultations and deliveries, patient exit interviews, and household surveys. Using multivariate regression models, we estimated the impact of the program on 55 outcomes in seven health system domains: structural quality, technical process quality, non-technical process quality, service fees, facility management, providers' satisfaction, and service coverage. We used random-effects meta-analysis to generate pooled average estimates within each domain. RESULTS: The PBF program improved the structural quality of health facilities by 4 percentage points (ppts) (95% CI 0.01-0.08), technical process quality by 5 ppts (0.03-0.07), and non-technical process by 2 ppts (0-0.04). PBF also increased coverage of priority health services by 3 ppts (0.02-0.04). Improvements were also observed for facility management (9 ppts, 0.04-0.15), service fee policies, and users' satisfaction with service affordability (14 ppts, 0.07-0.20). Service fees and health workers' satisfaction were not affected by the program. CONCLUSIONS: The results suggest that well-designed PBF programs can lead to improvements in most health systems domains relative to comparable unconditional financing. However, the large persisting gaps suggest that additional changes, such as allocating more resources to the health system and reforming the human resources for health management, will be necessary in DRC to achieve the ambitious global universal health coverage and mortality goals. TRIAL REGISTRATION: American Economics Association Trial registry AEARCTR-0002880.

The cost of public health interventions to respond to the 10th Ebola outbreak in the Democratic Republic of the Congo.

The 10th Ebola virus disease (EVD) outbreak in the Democratic Republic of the Congo (DRC) drew substantial attention from the international community, which in turn invested more than US$1 billion in EVD control over two years (2018-2020). This is the first EVD outbreak to take place in a conflict area, which led to a shift in strategy from a pure public health response (PHR) to a multisectoral humanitarian response. A wide range of disease control and mitigation activities were implemented and were outlined in the five budgeted Strategic Response Plans used throughout the 26 months. This study used the budget/expenditure and output indicators for disease control and mitigation interventions compiled by the government of DRC and development and humanitarian partners to estimate unit costs of key Ebola control interventions. Of all the investment in EVD control, 68% was spent on PHR. The remaining 32% covered security, community support interventions for the PHR. The disbursement for the public health pillar was distributed as follows: (1) coordination (18.8%), (2), clinical management of EVD cases (18.4%), (3) surveillance and vaccination (15.9%), (4) infection prevention and control/WASH (13.8%) and (5) risk communication (13.7%). The unit costs of key EVD control interventions were as follows: US$66 182 for maintaining a rapid response team per month, US$4435 for contact tracing and surveillance per identified EVD case, US$1464 for EVD treatment per case, US$59.4 per EVD laboratory test, US$120.7 per vaccinated individual against EVD and US$175.0 for mental health and psychosocial support per beneficiary. The estimated unit costs of key EVD disease control interventions provide crucial information for future infectious disease control planning and budgeting, as well as prioritisation of disease control interventions.

Optimized supply chain model reduces health system costs in DRC.

OBJECTIVE: In 2017, an optimized immunization supply chain (iSC) model was implemented in Equateur Province, Democratic Republic of the Congo. The optimized model aimed to address iSC challenges and featured direct deliveries to service delivery points (SDPs), longer replenishment intervals and increased cold chain capacity. This assessment examines iSC costs before and 5 months after implementing the optimized model. MATERIALS & METHODS: We used a nonexperimental pre-post study design to compare iSC costs before and after implementation. We applied an activity-based costing approach with a comparison arm to assess procurement, management, storage and transportation costs for three iSC tiers: Province (n = 1); Zone (n = 4) and SDP (n = 15). We included data from 3 treatment Zones and 11 treatment SDPs; 1 control Zone and 4 control SDPs. We used sample and population data to estimate iSC costs for the entirety of Equateur Province. RESULTS: In the period immediately before implementing the optimized model, estimated annual iSC costs were $974,237. Following implementation, estimated annual iSC costs were $642,627-a 34% ($331,610) reduction. This change in costs was influenced by a 43% ($180,313) reduction in SDP costs, a 67% ($198,092) reduction in Zonal costs and an 18% ($46,795) increase in Provincial costs. After implementing the optimized model, average iSC costs for treatment Zones was $6,895 (SD: $6,072); for the control Zone was $21,738; for treatment SDPs was $989 (SD: $969); and for control SDPs was $1,356 (SD: $1,062). CONCLUSIONS: We observed an absolute reduction in iSC costs in treatment Zones while control Zone post-implementation iSC costs remained the same or increased. The greatest cost reductions were for storage and transport at Zones and SDPs. Although cost implications of this model must continue to be evaluated over time, these findings are promising and will inform decisions around project expansion.

Mortality rates above emergency threshold in population affected by conflict in North Kivu, Democratic Republic of Congo, July 2012-April 2013.

The area of Walikale in North Kivu, Democratic Republic of Congo, is intensely affected by conflict and population displacement. Médecins-Sans-Frontières (MSF) returned to provide primary healthcare in July 2012. To better understand the impact of the ongoing conflict and displacement on the population, a retrospective mortality survey was conducted in April 2013. A two-stage randomized cluster survey using 31 clusters of 21 households was conducted. Heads of households provided information on their household make-up, ownership of non-food items (NFIs), access to healthcare and information on deaths and occurrence of self-reported disease in the household during the recall period. The recall period was of 325 days (July 2012-April 2013). In total, 173 deaths were reported during the recall period. The crude mortality rate (CMR) was of 1.4/10,000 persons/day (CI95%: 1.2-1.7) and the under-five- mortality rate (U5MR) of 1.9/10,000 persons per day (CI95%: 1.3-2.5). The most frequently reported cause of death was fever/malaria 34.1% (CI95%: 25.4-42.9). Thirteen deaths were due to intentional violence. Over 70% of all households had been displaced at some time during the recall period. Out of households with someone sick in the last two weeks, 63.8% sought health care; the main reason not to seek health care was the lack of money (n = 134, 63.8%, CI95%: 52.2-75.4). Non Food Items (NFI) ownership was low: 69.0% (CI95%: 53.1-79.7) at least one 10 liter jerry can, 30.1% (CI95%: 24.3-36.5) of households with visible soap available and 1.6 bednets per household. The results from this survey in Walikale clearly illustrate the impact that ongoing conflict and displacement are having on the population in this part of DRC. The gravity of their health status was highlighted by a CMR that was well above the emergency threshold of 1 person/10,000/day and an U5MR that approaches the 2 children/10,000/day threshold for the recall period.