Author: Thierry Mirindi, laureate of the USAB thesis prize 2024
Context & Scope of the problem
The fifth Millenium Development Goal (MDG) consisted on reducing the Maternal Mortality Rate by 75% in 2015 (WHO, 2015). However, at the end of the year 2015, the rate decreased by only 44% (WHO, 2015).
This low reduction of maternal mortality is mainly due to the low rate of Skilled Birth Attendance which was less than 50% in Sub Saharan African (SSA) countries (Prata et al., 2011). Skilled Birth Attendance means births are being attended by skilled health personnel. This low rate of Skilled Birth Attendance reflects a weak capacity of the state to provide a national insurance system for equal access to health services, a lack of programs that reinforce patients’ buying power and a predominance of a user fees regime since the 1980s, during the wave of Structural Adjustment Programs in most of African countries.
Thus, a user fees regime accompanied by the emergence of an unregulated private sector may be considered as a major cause of household impoverishment. The poverty incidence in the Democratic Republic of the Congo (DRC) varies between 65-85%, depending on the source/method (see for example Marivoet et al., 209). Indeed, in DRC, the household expenditures cover 40% of health services fees and 90% of health expenditures is made without a health insurance coverage (Barroy et al., 2014).
In 2008, such a health financing policy option has been crowded out by the abolishment of user fees in the framework of “The Access to Health-Care” programs for primary health care at health zones level mainly in Province Orientale, Kasai Occidental, Maniema, and South Kivu (Maini et al., 2014). These programs have shown diverse limits, however. Firstly, they supported only public health-care centres and hospitals. Secondly, the positive outcomes in terms of healthcare utilisation were short-lived. For a long-run perspective, a spotlight has been put on insurance programs. With a health insurance coverage rate less than 10%, the alternative health risks sharing mechanism is Community Based Health Insurance (CBHI)’s schemes (Laokri et al., 2018). These schemes have penetrated most of Sub Saharan African countries in the second half of the 20th century to reach poor people and vulnerable groups (Atim in Waelkens et al., 2017), with the intention to reduce the inequalities in healthcare utilisation between poor and rich.
However, the evidence is such that rich people are more likely to use healthcare services compared to poor people even if the latter are also insured (Gnawali et al. in Mirindi, 2021). Such a result underlines that insurance schemes are far from being the only factor of fairness in maternal care utilization.
The use of health services depends on both the conditions of supply and demand. These include parameters such as the availability and the quality of health services, the social structure, the health beliefs and the socio economic characteristics of patients (Chowdhury et al., 2007).
This study only focuses on the last set of factors i.e. the personal characteristics of users, because it indicates whether the existing heath system is in favour of people who need healthcare the most (people with poor health status are poor people in most cases) or those who are able to pay for health care.
What does the literature say?
The problem of exclusion of poor people from health care services has been in the news since the Structural Adjustment Programs, introduced in the 1980’s by the International Monetary Fund and the World Bank. These programs have established user fees as the best model for the health financing system and have led to the emergence of private institutions in a less regulated health sector, each applying its own price.
User fees
Considering the first side of the structural adjustment program, which focuses on a user fees program, there is a whole debate on the equity effect of a user fees system and this gave rise to two schools of thought.
For the first school, the equity effect of user fees depends on whether governments are introducing supportive measures to promote service improvements and to tackle differences in the ability to pay among citizens through exemption policies for disadvantaged groups (Russel & Gilson, 1997). However, implementing exemption policies is a complex process because in many countries identifying who is poor is not a straightforward task (Bennett & Ngalande-Banda 1994). Exemption policies are also stained with several limitations. On the one hand, the scope and content of the benefits package covered by these policies seems to vary widely across countries. On the other hand, the selection of a given set of maternal health services (Benin, Mali, and Senegal policies cover only care for pregnant women while other countries also include care for the newborn) was based on political objectives rather than technical maternal health advice (Richard et al., 2013). The non-involvement of an appropriate technical workforce and the lack of preparation for a user fees removal in SSA countries, resulted in poor design of the reform and weaknesses in the policy formulation and implementation process (Meessen et al., 2011). A poorly defined exemption mechanism may protect those who are not poor (“lowering revenues unnecessarily”) or not protect those who are poor (“adversely affecting equity”) (Bennett & Ngalande-Banda, 1994). This was the case in Kenya and Ghana and several other African countries where government employees were exempted (Bennett & Ngalande-Banda 1994). Other policies go beyond this, by including the population sub-group or the geographical areas covered. This is the case for Kenya, Nigeria, and Senegal, where the policy covers some targeted regions and not the whole country.
For the second school, the improvement of quality of health services, that can be expected when implementing a fee policy, depends on the way in which revenues collected through user fees are being used (Lagarde & Palmer, 2011). Thus only a user fee combined with quality improvement may make public care relatively more affordable to the majority (McPake, 1993). For example, Lagarde & Palmer (2011) show that introducing user fees results in a decrease in utilisation of health services ranging from 51% to about 5%; but introducing user fees alongside quality improvements (full stock of drugs, the establishment of management committees, etc.) yielded positive outcomes in terms of utilisation in countries that have been able to reallocate resources collected through user fees.
Private institutions
Considering the second side of the structural adjustment program, which focuses on private institutions, the results of this program were not the same everywhere. This emphasizes the context-related effect, and more specifically the way in which the healthcare system as a whole is regulated. In many developing countries, the emergence of the private sector in an unregulated health sector has led to high costs of health care and low efficiency i.e. rising prices, reduced utilisation, and an increase in inequality in both access and health outcomes (Marriott, 2009). Thus, since the structural adjustment program, there has been an emergence of private health facilities charging different prices for the same service and, at worst, different prices within the same health facility for patients with the same disease (Ntambue et al., 2014). This race for profit has been accentuated by the deregulation of the health sector leaving poor people excluded from the health system (Mackintosh & Koivusalo, 2004). Data from 44 middle- and low-income countries suggest that higher levels of private-sector participation in primary health care are associated with higher overall levels of exclusion of poor people from treatment and care (Mackintosh & Koivusalo, 2004), especially women.
However, In Ethiopia, Kenya, Nigeria, and Uganda, more than 40 percent of people in the lowest economic quintile receive health care from private, for-profit providers (International Finance Corporation. 2007). In addition, over 50 percent of the rural populations of Nigeria and Uganda use for-profit private healthcare (International Finance Corporation. 2007). This evidence shows that the private sector takes care of people from a wide income distribution, including the poor, and has a broad geographic reach among rural populations. This supports the idea that liberal policies or the private sector can serve poor people too.
What do the results say?
Using a Horizontal Inequality approach to analyse the dataset of the second round of Demographic and Health Surveys (DHS-DRC II), we found that inequities exist among the Congolese population: Whereas the utilization of maternal healthcare is high among women in upper quintiles even after controlling for need factors (that reflect the health status of individuals such as anthropometric and self-reported heath status and can be distinguished from non need factors that mainly reflect the ability to pay for health care or the socio economic characteristics of individuals and their households). This means that the health system in DRC is much more accessible for people who are able to pay for health care instead of poor people who are most in need of it.
Factors that are found to be at the root of the inequalities in DR Congo are the wealth status of the household, the level of education of both the woman and her husband, the insurance status of the household or the woman, the residence of the household, the distance to health facilities and the type of health facility where the woman made her first prenatal visit.
What are the policy implications?
Given the effect of female education on equity, the government should promote education for all and especially women’s education by putting in place incentive policies. These policies may include free primary and secondary school at least for the vulnerable, especially women, scholarships for women, etc.
Women from rural areas are less likely to use Skilled Birth Attendance services than women living in urban areas. The government is called upon to increase health coverage in rural areas and to invest in a large-scale awareness-raising campaign to explain to rural women the advantages of giving birth at heath facilities and the risks of giving birth at home.
Women with insurance are also more likely to use postnatal care than those without insurance. The government needs to expand health coverage through policies on health insurance. This may be reached by strengthening the different insurance schemes, namely the Community Based Health Insurance, so that more poor people can be covered
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