The dilemma facing organizations in defining who are indigent is finding a balance between the people who truly need support for health care and those who can afford the health care costs. Either way, assessing or setting up a well-functioning system that supports indigent care is time-and labor-intensive in a chronic crisis situation.

In the Democratic Republic of the Congo (DRC), each agency has found a different resolution to the indigent dilemma. The International Rescue Committee (IRC) works with coupons and a maximum quota for the indigent for each health zone. This is a system of enfranchisement in which coupons given to the indigent substitute for pay for services, a bit like a ration card in a refugee camp. Using the criteria, local health committees determine the indigent status of those who ask for coupons. The health nurse also checks their status; in this way, the local health committee and the health nurse can control each other’s work. The IRC reimburses the health centers for the coupons that they receive. While the main disadvantage is that the system takes up considerable time and resources, it has four strong advantages:

  • The integrity of the health system is maintained, because health centers continue to generate revenues from indigent treatment.

  • The more indigent patients the health staff treats, the more money it earns. In other words, there is no disincentive for treating the indigent.

  • There is no pull effect of free health care for the indigent from other zones.

  • It allows the health staff and the IRC to monitor the indigent and their (impact on) health care.1

Except for the IRC, none of the organizations currently employs an indigent care system with coupons. Merlin reimburses the drugs, but not the consultations, for the indigent. The other two organizations do not employ explicit indigence criteria and do not reimburse indigent treatment. While these organizations maintain that the indigent are treated for free,


Some health staff was concerned about the continuation of the coupon system, if IRC would leave. In this sense, the IRC needs to develop and explain a clear exit strategy. Currently, the part of the revenues allocated for buying medicine is put into a savings account. Using these savings can help ensure continuation of local health care for an extended period of time once the international organizations leaves (see Table 3-1).

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