One of the greatest humanitarian management dilemmas in chronic crisis situations is the trade-off between subsidised care, which improves public health, and raising fees, which can help economic sustainability but may also lead to exclusion of the poorest people. However, there is very little empirical data available on this subject.

Ruhr University Bochum (Germany) together with the London School of Hygiene and Tropical Medicine (UK) looked at the work of three non-governmental organisations (NGOs) in the eastern regions of the Democratic Republic of the Congo (DRC). It looked at their efforts to improve standards of the local health services and increase the numbers of users.

The DRC remains unstable. It suffers from extremely high mortality rates, armed violence and a weak public health system with no support from central government. Health clinics are largely self-financing. Patients must pay for consultations and drugs. The revenue generated from patients is meant to cover the cost of building repairs, medical supplies and staff wages which have not been paid by the government for more than a decade.

The research for this study took place between 2001 and 2005. The researchers studied financial documents, interviewed patients and staff, and observed the NGOs in action. The three NGOs have different approaches to caring for the poorest patients. One organisation, the International Rescue Committee (IRC), provided poor people with coupons so they did not have to pay for care. Clinics were then reimbursed for their treatment. The other two organisations, Malteser and ASRAMES, provided free treatment for poor people, but had no set criteria or formal systems in place.

The study found that:

• The three NGOs had different pricing structures to accommodate adults and children or urban and rural residents.
• IRC clinics were in a smaller stable area, allowing them to provide more regular supplies of drugs.
• IRC supervisors visited the clinics on a weekly basis while Malteser and ASRAMES staff visited less frequently.
• For two of the organisations (IRC and Asrames) revenue covered up to 46 percent of a clinic’s running costs. However, if poor people were treated free of charge, as in the case of the IRC supported clinics, the clinic’s income only covered 16 percent of its outgoings.
• Clinics which made less money had much higher numbers of people attending because they were not charging poor people for treatment.

More people would use the clinics if drug supplies were regular, the clinic staff were well supervised and health care was free for poor people. Clinics need to receive drugs free of charge along with other subsidies if they are to pay staff wages and meet running costs. In a period of crisis increasing access to health care must take priority over trying to recover costs.

In order to improve the quality of health care in a period of long-term instability NGOs need to:

• put in place a formal system which reimburses the clinic for the care it has provided free of charge 
• find methods to ensure clinics are stocked with regular supplies of essential drugs
• agree on a fee structure and compare usage rates in coordination with other organisations, including national health authorities, so that they are working together and not against each other
• provide local supervisors who can spend more time at the clinics and less time travelling
• have long-term plans in place including how they will hand over to local management.

Source(s):
‘NGO management and health care financing approaches in the Eastern Democratic Republic of the Congo’, Global Public Health 1(2), pages 157-172, by D. Dijkzeul and C.A. Lynch, 2006
‘Supporting local health care in a chronic crisis: management and financing approaches in the eastern Democratic Republic of the Congo’, National Research Council of the National Academies, roundtable on the demography of forced migration, Committee of Population, Division of Behavioural and Social Sciences and Education and Program on Forced Migration and Health, Joseph L. Mailman School of Public Health, Columbia University, Washington, DC: The National Academies Press, by Dennis Dijkzeul and Caroline Lynch, 2005
ijkzeul and Caroline Lynch, 2005

id21 Research Highlight: 16 January 2007

Further Information:
Caroline Lynch
Disease Control and Vector Biology Unit
Department of Infectious and Tropical Diseases
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT
UK

Tel: +44 (0) 20 7927 2213
Contact the contributor: caroline.lynch@lshtm.ac.uk

Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK

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