4
Discussion

The results of this research provide a multifaceted picture. Under some circumstances, cost recovery can raise more than a third of operational costs, but other factors, sometimes counterintuitive ones, are also important, especially when it comes to increasing utilization. As seen in Figures 3-1, 3-2, and 3-3, lower fees can lead to higher utilization, but not in all cases and not necessarily at rates that are put forward as minimum standards.

Regarding revenues from cost sharing, an increase in utilization because of quality of care and availability of drugs does not sufficiently raise revenues to cover all operational costs at health facilities. In fact, the measures taken by nongovernmental organizations (NGOs) to ensure adequate drug supplies and supervision of those supplies contribute to higher utilization, but they also lead to a higher overall financial burden on the health system. The NGO costs, however, are rarely taken into account, and information on this remains sketchy.

One conclusion of this study is that, in a chronic crisis, in some circumstances no user fee should be implemented in order to remove financial barriers (for example, during epidemics or large population displacements) or there should be a reimbursement system.

The problem facing NGOs is defining when and where a policy of no fees should be applied in a situation that is constantly changing. For example, the security and economic conditions, the role of donors, and the



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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo 4 Discussion The results of this research provide a multifaceted picture. Under some circumstances, cost recovery can raise more than a third of operational costs, but other factors, sometimes counterintuitive ones, are also important, especially when it comes to increasing utilization. As seen in Figures 3-1, 3-2, and 3-3, lower fees can lead to higher utilization, but not in all cases and not necessarily at rates that are put forward as minimum standards. Regarding revenues from cost sharing, an increase in utilization because of quality of care and availability of drugs does not sufficiently raise revenues to cover all operational costs at health facilities. In fact, the measures taken by nongovernmental organizations (NGOs) to ensure adequate drug supplies and supervision of those supplies contribute to higher utilization, but they also lead to a higher overall financial burden on the health system. The NGO costs, however, are rarely taken into account, and information on this remains sketchy. One conclusion of this study is that, in a chronic crisis, in some circumstances no user fee should be implemented in order to remove financial barriers (for example, during epidemics or large population displacements) or there should be a reimbursement system. The problem facing NGOs is defining when and where a policy of no fees should be applied in a situation that is constantly changing. For example, the security and economic conditions, the role of donors, and the

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo quality of the local counterparts influence utilization and the quality of local health care, but these issues have been difficult to improve by the four NGOs alone. From the results presented, we draw the following conclusions: 1. Access is increased by lowering fees, especially by reclassifying children between ages 5 and 15 in a lower category for fees. The jump in utilization rates in facilities of the International Rescue Committee (IRC) closely followed the reclassification of age groups, meaning that fees were lowered for 5-15 year olds. Studies have shown that while utilization rates for children under age 5 increased when fees were dropped, the rates increased even more for those over age 5—suggesting that health care for young children is the priority in a household even when there are fees to pay (Burnham et al., 2004). When fees are reduced or dropped for older groups, this increases their access to care. Data suggest that this has happened in IRC-supported zones. 2. Reimbursement to health facilities by NGOs for services rendered to indigent patients sustains the ability of health facilities to serve indigent populations. Formal schemes in which the indigent are identified, classified, and recorded as patients ensure that those who cannot pay for health care are covered by the health system. These schemes allow staff to treat indigent in the health system knowing that their services will be reimbursed by the NGO. ASRAMES and Malteser, while recognizing the existence of the indigent, left it to the health facilities to deal with these populations. The results of this policy are unknown. However, one could imagine that without a safety net of reimbursement, the health facility staff were more stringent in their criteria for indigence and who would receive treatment depending on their condition. 3. In cases of an indigent system with reimbursement, cost recovery contributes between 30 and 45 percent to the operational costs of a health facility. Within IRC-supported health facilities, the cost of indigent reimbursements is almost two-thirds that of revenues received from nonindigent utilization. In effect, if the health system were to provide treatment for indigent populations at cost to the health facility, the cost-sharing revenues provided would drop by approximately 30 percent (from 46 to 16 percent—IRC figures). Beyond the operational costs at health facilities, the chronic situation in the DRC requires that emphasis is placed on training and capacity build-

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo ing. To this end, heavy external support is required to ensure that the utilization, which ensures revenue, is sustained. In health facilities without a defined indigent system, cost-recovery rates are above 30 percent, thus above the standards set by the World Bank for revenues to offset operational costs. However, utilization rates remain well below standards set by both the Sphere guidelines (3-4 visits per person per year) and donors (1 visit per person per year). Facilities that support indigent care and gain reimbursements will have the highest utilization, but possibly the lowest overall cost recovery if the costs of the supporting NGO are taken into account. This is a crucial consideration, and the NGOs should decide whether they prioritize access to health care for all or cost recovery to sustain the health system in an ongoing crisis. All four NGOs should prioritize access according to their mandates in the eastern DRC. The potential impact of cost sharing following Sphere guidelines would result in 100 percent recovery of health facility operational costs, with remaining monies to support supervision, administration, and transport. However, the feasibility of increasing utilization to these levels is unlikely. 4. Intensive external support in the form of NGO presence and ongoing operation is required in chronic crises to ensure continued access. All organizations consider supervision and concurrent capacity building important; the highest utilization was recorded in zones with the most intensive supervision, the lowest in zones with only little or virtually no supervision. As stated, finding a balance between the hands-off contract approach and the intensive supervision approach ultimately depends on the managerial and professional skills of the local health system staff. In chronic crises, knowledge of recent developments in health care is minimal, meaning that health personnel usually lack skills and capacity. Any program with an aim to decrease morbidity and mortality must, as a prerequisite, ensure that health teams are capable of delivering the care required. Our qualitative research suggests that over time, intensive supervision contributes to: Quality of interaction with patients. Prevention of ruptures in stock. Professionalization. Rational prescription. Improved health care information and accounting systems. Improved health infrastructure (e.g., cleaner or better maintained buildings and equipment). Better interaction with health committees.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo Accountability at health facility level to ensure that fee prices are enforced and higher fees are not requested of patients by health staff. External support through intense supervision thus plays an important role in the utilization of health facilities, but this role is difficult to quantify with the data currently available. 5. Continued support by donors will remain necessary in the near future. Additional measures, such as free drugs and direct subsidies, are necessary to ensure that revenues are high enough to pay for staff incentives and running costs. 6. Management approaches that balance the requirements of the donor organizations and the needs of the local health management are successful in ensuring that both parties are pressured into reducing fees and supporting these fees. Careful negotiations are needed with both sides. Bearing in mind that NGO funding is normally for 6-month periods, convincing local health authorities to reduce fees in facilities in which external support could be withdrawn within months is daunting. Similar sensitivities can be found with donors who are reluctant to fully or partially fund health programs without seeing some transfer of responsibility (i.e., user fees) to the host population over a short period of time. 7. Size and security of the health zone(s) served matter. The IRC has safer and more frequent access to the population because it serves two zones close by, whereas ASRAMES serves an entire province divided by a front line. Even in zones rather similar to IRC zones, Malteser still faced a more stringent security curfew, which meant that health staff going to the field had to leave the office later and also leave the health facilities earlier and could carry out fewer supervisory tasks. 8. Fees should be adapted regularly on the basis of changes in household income due to security and economic changes. Fees should also be advertised to ensure that the population knows what it can expect at a health facility and also to ensure that staff do not try to impose additional or increased costs. Poor knowledge of the health center fees along with weaker supervision can lead to under-the-counter takings by health staff. 9. While utilization has increased for all agencies but one, it is not clear how the access of the total population changes over time. In other words, what exactly is the capacity of the population to continue to pay for health services, and how fast is this capacity changing (deteriorating)? Which groups currently do not attend? A well-functioning indigent system partly addresses these questions, but more research is necessary.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo IMPLICATIONS AND PRACTICAL CONSIDERATIONS The four organizations can take several steps improve the overall health system. Essentially, they need to combine some of their approaches to ensure sustainability. Donor Management: Improve coordination among donors, based on better quantitative and qualitative data of the organizations (including goal setting and impact measurement), which could facilitate field-level operations considerably. Better quantitative studies on the results of the organizations and the local situation could also contribute to a higher degree of accountability. Finally, longer funding periods would reduce paperwork, in particular for proposal writing, and facilitate the interaction of the four NGOs with the local health care system, as well as (joint) strategic planning. Local Management: Use the contract approach to foster local ownership of targets and procedures, to delineate responsibilities and mutual expectations, and to reward performance and to punish malfunctioning (either malfeasance or poor performance). This will facilitate a move from the current hands-on contract and intense supervision approaches to a later hands-off contract approach. Train staff (zone bureau, reference health centers, health centers, or hospitals) and health committees to build capacity through local participation and the promotion of preventive health care.1 Subsidize preventive services and provincial health inspection and zone bureaus to help build capacity. Decentralize NGO operations in order to improve supervision and reduce costs. A supervisor traveling from a central office to field sites may have limited access to those health facilities and spend limited time with health staff. A decentralized system of supervisors could provide greater coverage at reduced cost. 1   One project official remarked that training of health committee members improved their status in the community and also contributed to a more positive attitude toward helping their communities.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo Work through local structures (provincial health inspection, zone bureau, health committees) and discuss ways of phasing out support depending on their capacity and financial position. The hard part is determining which structures are appropriate and capable enough to work with. Although working through local structures ensures some cohesion and prevents parallel networks from being set up, the problem of how to hold local management accountable requires ongoing attention.2 This research suggests such accountability can be enhanced by intensive supervision, as a form of evaluation with capacity building, and a participatory contract approach. Moreover, the organizations also need to establish clear, long-term strategies, including hand-over and exit strategies. For example, Médecins Sans Frontières-Hollande’s support in creating ASRAMES had important long-term benefits for the whole North Kivu province that continued after its partial withdrawal. Clear long-term strategies will facilitate a move from the current hands-on contract and intense supervision approaches to a later hands-off contract approach. Monitoring and Evaluation: Set more ambitious goals. Currently, the NGOs set safe goals that they will be able to reach, for example with utilization. As with Merlin’s contracts in the field, setting the right targets for the organizations and the donors is important for the functioning of the health system. If intelligently combined with regular impact measurement, such goals could be an important steering mechanism for both donors and the local supervisory system. Compare NGOs more often through benchmarking on standards, goals, and impact. Common measurement, evaluation, and analysis methods can be introduced. To this end, the organizations should have utilization and cost data available. Utilization rates between organizations should also be compared more often, in the case of NGOs supporting nearby or neighboring health zones where displacement from one to the other may 2   For example, despite its high level of support and concomitant supervision, IRC is not perceived as a local authority. Most people view the organization as an outside supplier. As a result, IRC staff members sometimes struggle to hold the zone bureau and other health staff accountable. One nutritional survey could not be carried out, because the health zone bureau asked for a very high daily allowance for its staff.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo be occurring. Currently, the organizations employ different standards of utilization. Coordination among NGOs on cost-sharing schemes, as well as benchmarks, will reduce the “pull effect” created by having a lower fee in one area and a higher one in another. Discuss the dubious nature of population figures as an issue that confronts the NGOs in terms of measuring the impact of their programs. Measuring utilization, for example, or incidence of disease is difficult when the population figures are unknown and changing. Revenues: Develop a mechanism with local management and donors whereby health care is declared free during epidemic outbreaks. Provide an indigent care system with reimbursement for services rendered (and provide free health care when the number of indigent becomes too large). In normal situations, the constant displacement of communities causes a problem in defining who can and cannot pay for health care. The issue of indigence (within which displaced persons are defined) needs to be addressed explicitly, as the IRC and, to a lesser extent, Merlin have done. Spend revenues as much as possible at the location where they have been generated (see Merlin’s experience with revenue allocation). Health staff are reluctant to transfer revenues to zone bureau and provincial health inspection. Direct quality improvements (e.g., better infrastructure, continuous drug supply) can lead to higher attendance. Supplies: Develop and formalize ways of ensuring drug stocks at health facilities in a situation of ongoing insecurity. In some areas, the health committees bring drugs back to their houses at night in order to safeguard them. In other areas, the pharmacy was disguised as the staff toilet so when looting occurred rebels found only a limited stock of medications at the dispensary. While this leads to questions of accountability at the health facility and committee levels, it is an area worth investigating to ensure continued stocks. Establish more preventive approaches, as for example has been done with bed nets and community education to prevent malaria.

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo FURTHER RESEARCH This research provides a comparison on the operations of four organizations. Follow-up research should pay more attention to the actual experiences and opinions of the local populations, whether they attend health centers or not. Ideally, such a follow-up public health study would include checking health records and quantitative questionnaires, such as patient exit and household surveys, to study in depth the local health needs, actual activities in the health centers, and the local management structures. A number of research topics could thus be elucidated: Donor Management: The impact of the different donors, in particular the Humanitarian Aid Office of the European Union and the Office of U.S. Foreign Disaster Assistance, at the field level could be studied more, for example in terms of effectiveness and downward accountability. Internal Management: The optimal fee system requires exemptions for specific services and waivers for specific groups as well as regularly adjusting fees. Identifying better ways for adjustment with regard to the changing (diminishing) capacity to pay for services remains a useful topic for further study. For example, this study did unearth some data on the debts of the health centers, as well as on the debts of the patients (Table 3-1); the use of these as indicators of ability to pay could be studied further. The impact of different cost-sharing schemes on treatment-seeking behavior is also an important topic that requires more detailed attention. The microeconomics of health facilities requires further study, especially in terms of revenues and the distribution of those revenues among the operational costs of health facilities. A more in-depth assessment of revenues provided from cost recovery as a part of overall costs of international and local NGO support would enable a greater overview as to how much cost-recovery revenues contribute to overall support of a health system in chronic crises. Ideally, the NGOs could do more to compare their total costs, as well as their results in terms of geographical and social balance (ethnic groups, gender, income class, and so on). The latter may also be important for gaining a better under-

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Supporting Local Health Care in a Chronic Crisis: Management and Financing Approaches in the Eastern Democratic Republic of the Congo standing of the local conflict context. In reality, the likelihood of this occurring is minimal while NGOs compete for donor funding. Local Management: Cooperation with the private sector, for example with private pharmacies or traditional healers, merits more attention. Similarly, a better understanding of local coping mechanisms, for both patients and health staff, may provide interesting opportunities for providing health care, for example, to extended families or with accepting payments in kind. The quality of the provincial health inspections, zone bureaus, and health committees differs. Their organization and management requires further comparative research. Such a study would also facilitate making choices or finding combinations between the hands-off contract and intensive supervision approaches. In a similar vein, cooperation with the health committees differs among the organizations, which should be studied because local participation also offers opportunities for rebuilding in other sectors. Rumors of corruption continuously circulate around the (local) management of the health systems. Sometimes, it seems this corruption is just a matter of everyday survival in a tough situation, but at other times it may be linked to exploitative violence. Understanding and dealing with corruption requires far more attention. In the final analysis, there is much that the international nongovernmental organizations can do and are doing to improve health care and raise utilization in the eastern Democratic Republic of the Congo. The organizations are implementing and developing useful management and finance approaches that join relief and developmental aspects. Further research should combine the study of these approaches with more attention to the experiences and opinions of the local population.