Payment Subsidy and Equity in Access to Health Care: The Case of the Democratic Republic of Congo

Abstract

Since the 2000s, the Democratic Republic of Congo has adopted national policies to phase out direct payment at the point of service to make health care more accessible. The objective of this study is to measure inequalities in access and financing of a subsidised health system. The measurement of inequalities in access and financing was applied to data from the Improved Monitoring for Action (N = 475 households in the Tshilenge health zone, East Kasai province, Democratic Republic of Congo), which is part of the evaluation of the performance of the health system through high-impact interventions for maternal, newborn and child health. The concentration curve and index (CI) method was used to assess the degree of inequality in the distribution of health care consumption and expenditures. A negative CI indicates a disproportionate concentration of subsidies among the poor, while a positive CI indicates that the subsidy is favourable to the rich; a CI of zero indicates perfect equity. In addition, the Kakwani Progressivity Index (KPI) was used to assess the progressivity of direct household spending on care. A positive value of the KPI indicates the progressivity of the system and a negative value its degressivity. The indices of concentration of use are respectively 0.034 for self-medication and -0.050 for use of a health facility, and the indices of standardised use are 0.00 in both cases. Comparison of the standardised and non-standardised concentration of use curves shows that standardisation reduces the differences between quintiles: there is horizontal equity of use after indirect standardisation. All Lorenz curves are below the standard of the living curve (the KPIs are significantly negative). Health expenditure is therefore all-regressive. The measurement of the degree of equity showed that there is imperfect equity in the use of care and that the system of financing care is inequitable and regressive. Direct household spending increases inequities in access. The contribution is greater for the lowest income groups. The low budget of the health sector prohibits universality and free access to services by producing a recourse to self-medication and renunciation of care.