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Impact of a free care policy on the utilisation of health services during an Ebola outbreak in the Democratic Republic of Congo: an interrupted time-series analysis
  1. Yuen W Hung1,
  2. Michael R Law2,
  3. Lucy Cheng2,
  4. Sharon Abramowitz3,
  5. Lys Alcayna-Stevens4,
  6. Grégoire Lurton5,
  7. Serge Manitu Mayaka6,
  8. Romain Olekhnovitch5,
  9. Gabriel Kyomba6,
  10. Hinda Ruton2,7,
  11. Sylvain Yuma Ramazani8,
  12. Karen A Grépin1,9
  1. 1 Health Sciences, Wilfrid Laurier University, Waterloo, Ontario, Canada
  2. 2 Centre for Health Services and Policy Research, The University of British Columbia, Vancouver, British Columbia, Canada
  3. 3 Independent Consultant, Brookline, Massachusetts, USA
  4. 4 Department of Anthropology, Harvard University, Cambridge, Massachusetts, USA
  5. 5 Bluesquare, Brussels, Belgium
  6. 6 Public Health School of Kinshasa, Université de Kinshasa, Kinshasa, The Democratic Republic of Congo
  7. 7 School of Public Health, University of Rwanda, Kigali, Rwanda
  8. 8 Ministry of Public Health, Kinshasa, The Democratic Republic of Congo
  9. 9 School of Public Health, University of Hong Kong, Pokfulam, Hong Kong SAR
  1. Correspondence to Dr Karen A Grépin; kgrepin{at}


Background During past outbreaks of Ebola virus disease (EVD) and other infectious diseases, health service utilisation declined among the general public, delaying health seeking behaviour and affecting population health. From May to July 2018, the Democratic Republic of Congo experienced an outbreak of EVD in Equateur province. The Ministry of Public Health introduced a free care policy (FCP) in both affected and neighbouring health zones. We evaluated the impact of this policy on health service utilisation.

Methods Using monthly data from the national Health Management Information System from January 2017 to January 2019, we examined rates of the use of nine health services at primary health facilities: total visits; first and fourth antenatal care visits; institutional deliveries; postnatal care visits; diphtheria, pertussis and tetanus (DTP) vaccinations and visits for uncomplicated malaria, pneumonia and diarrhoea. We used controlled interrupted time series analysis with a mixed effects model to estimate changes in the rates of services use during the policy (June–September 2018) and afterwards.

Findings Overall, use of most services increased compared to control health zones, including EVD affected areas. Total visits and visits for pneumonia and diarrhoea initially increased more than two-fold relative to the control areas (p<0.001), while institutional deliveries and first antenatal care increased between 20% and 50% (p<0.01). Visits for DTP, fourth antenatal care visits and postnatal care visits were not significantly affected. During the FCP period, visit rates followed a downward trend. Most increases did not persist after the policy ended.

Interpretation The FCP was effective at rapidly increasing the use of some health services both EVD affected and not affected health zones, but this effect was not sustained post FCP. Such policies may mitigate the adverse impact of infectious disease outbreaks on population health.

  • health policy
  • health services research
  • other infection, disease, disorder, or injury
  • viral haemorrhagic fevers

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  • Handling editor Valery Ridde

  • Twitter @myclaw, @anthromama, @grlurton, @SergeMayaka, @KarenGrepin

  • Contributors MRL, SI, SMM and KG conceived the idea. YWH, MRL, SI, LA-S, GL, SMM, HR and KG developed the protocol and contributed to the study design. GL and RO provided study data and assisted with data management. YWH and LC managed and analysed the data, in collaboration with MRL. YWH and KG drafted the manuscript. All authors reviewed the manuscript and contributed to the revision of the manuscript, and approved its final version. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

  • Funding International Development Research Centre, Social Sciences and Humanities Research Council, Canadian Institutes of Health Research, and the AXA Research Fund. This project received funding from the Rapid Research Fund for Ebola supported by the International Development Research Centre, Social Sciences and Humanities Research Council, and Canadian Institutes of Health Research. Dr. Law received salary support through a Canada Research Chair and a Michael Smith Foundation for Health Research Scholar Award. Dr. Grépin also received salary support through a Canada Research Chair.

  • Disclaimer The funders of the study had no role in study design, data collection, data analysis, interpretation of data, or writing of the report.

  • Map disclaimer The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.

  • Competing interests MRL has consulted for Health Canada, the Health Employees’ Union, the Conference Board of Canada, and provided expert witness testimony for the Attorney General of Canada. Bluesquare has ongoing contracts with a variety of organisations in DRC including the Ministry of Health and the World Bank. SI, LA-S, SMM, and HR were paid as individual consultants as part of their collaboration with this project.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data may be obtained from a third party and are not publicly available. Data are obtainable from the Ministry of Public Health in the DRC.

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