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      Improving financial access to health care in the Kisantu district in the Democratic Republic of Congo: acting upon complexity

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          Abstract

          Background

          Comzmercialization of health care has contributed to widen inequities between the rich and the poor, especially in settings with suboptimal regulatory frameworks of the health sector. Poorly regulated fee-for-service payment systems generate inequity and initiate a vicious circle in which access to quality health care gradually deteriorates. Although the abolition of user fees is high on the international health policy agenda, the sudden removal of user fees may have disrupting effects on the health system and may not be affordable or sustainable in resource-constrained countries, such as the Democratic Republic of Congo.

          Methods and Results

          Between 2008 and 2011, the Belgian development aid agency (BTC) launched a set of reforms in the Kisantu district, in the province of Bas Congo, through an action-research process deemed appropriate for the implementation of change within open complex systems such as the Kisantu local health system. Moreover, the entire process contributed to strengthen the stewardship capacity of the Kisantu district management team. The reforms mainly comprised the rationalization of resources and the regulation of health services financing. Flat fees per episode of disease were introduced as an alternative to fee-for-service payments by patients. A financial subsidy from BTC allowed to reduce the height of the flat fees. The provision of the subsidy was made conditional upon a range of measures to rationalize the use of resources.

          Conclusions

          The results in terms of enhancing people access to quality health care were immediate and substantial. The Kisantu experience demonstrates that a systems approach is essential in addressing complex problems. It provides useful lessons for other districts in the country.

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          Most cited references39

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          Building the Field of Health Policy and Systems Research: Social Science Matters

          In the second in a series of articles addressing the current challenges and opportunities for the development of Health Policy and Systems Research (HPSR), Lucy Gilson and colleagues argue the importance of insights from the social sciences.
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            A scoping review of the literature on the abolition of user fees in health care services in Africa.

            In Africa, user fees constitute a financial barrier to access to health services. Increasingly, international aid agencies are supporting countries that abolish such fees. However, African decision-makers want to know if eliminating payment for services is effective and how it can be implemented. For this reason, given the increase in experiences and the repeated requests from decision-makers for current knowledge on this subject, we surveyed the literature. Using the scoping study method, 20 studies were selected and analysed. This survey shows that abolition of user fees had generally positive effects on the utilization of services, but at the same time, it highlights the importance of implementation processes and our considerable lack of knowledge on the matter at this time. We draw lessons from these experiences and suggest avenues for future research.
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              Health systems, systems thinking and innovation.

              Rifat Atun (2012)
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                Author and article information

                Journal
                Glob Health Action
                Glob Health Action
                GHA
                Global Health Action
                Co-Action Publishing
                1654-9716
                1654-9880
                05 January 2015
                2015
                : 8
                : 10.3402/gha.v8.25480
                Affiliations
                [1 ]Belgian Aid Agency, Kisantu, DR Congo
                [2 ]Hospital of Kisantu, Kisantu, DR Congo
                [3 ]Provincial Health Team of Bas Congo, Matadi, DR Congo
                [4 ]Institute of Tropical Medicine, Antwerp, Belgium
                [5 ]Belgian Aid Agency, Brussels, Belgium
                Author notes
                [* ]Correspondence to: Stéphanie Stasse, EU Delegation DRC/14ème niveau, Immeuble BCDC, Boulevard du 30 juin, Kinshasa/Gombe, DR Congo, Email: stephaniestasse@ 123456yahoo.co.uk

                Responsible Editor: Lars Lindholm, Umeå University, Sweden.

                Article
                25480
                10.3402/gha.v8.25480
                4307026
                25563450
                a811f886-fe95-49c2-981d-ece584aacab3
                © 2015 Stéphanie Stasse et al.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 26 August 2014
                : 24 October 2014
                : 27 November 2014
                Categories
                Original Article

                Health & Social care
                access,payment modalities,health district systems,regulation,action research,systems thinking

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