Willingness to Pay for Primary Health Care Services and Associated Factors in Eastern Kasai, Democratic Republic of the Congo

This study in Eastern Kasai, DRC, reveals that while a majority of households express a willingness to pay for primary health care, this willingness is highly sensitive to service costs and strongly influenced by socioeconomic factors and perceived quality, highlighting the urgent need for prepayment mechanisms and quality improvements to advance Universal Health Coverage.

The Gist

Imagine the healthcare system in Eastern Kasai, a province in the Democratic Republic of the Congo, as a massive, crowded marketplace. For years, if you wanted to buy medicine or see a doctor, you had to pull cash out of your own pocket right then and there. This is called "paying out-of-pocket." The problem is, many people in this marketplace are so poor that even a small price tag stops them from buying what they need to stay healthy.

The government wants to change this system to make sure everyone can get care, a goal known as "Universal Health Coverage." But to do that, they need to know: If we ask people to chip in a little bit of money beforehand (like a subscription fee), will they actually do it?

This study is like a giant survey conducted in July 2025 to answer that exact question. Here is what the researchers found, broken down simply:

1. The "Price Tag" Test

The researchers asked 633 families, "Would you pay for healthcare?"

• The Good News: About 7 out of 10 families said, "Yes, we would pay for our own health," and an even higher number (73%) said, "Yes, we'd pay for our family members."
• The Catch: This "Yes" is very sensitive to the price. Think of it like a vending machine.
  • If the machine is free, almost everyone (95%) wants to use it.
  • If the machine costs a little bit (like a cup of coffee), most people still say yes.
  • But as the price goes up to the cost of a week's groceries, the number of people willing to pay drops like a stone. At the highest prices tested, only about 6% of people said they would pay.

2. Why People Said "No"

When people refused to pay, they gave two main reasons, which acted like two different walls blocking the door:

• The Wallet Wall: They simply didn't have the money. Many were unemployed, deeply in debt, or just earning too little to spare anything extra.
• The Quality Wall: Even when the service was free, some people said, "No thanks." Why? Because they felt the care they would get was poor quality. It's like saying, "I won't buy a meal even if it's free, because I know the food will be bad."

3. Who Was Most Willing to Pay?

The study looked at who was more likely to say "Yes" and found three groups standing out, like three pillars holding up a roof:

• The Workers: People with a steady job were almost twice as likely to say yes compared to those without work. If you have a paycheck, you can plan for the future.
• The Rural Residents: Surprisingly, people living in the countryside were more willing to pay than those in the city. The researchers suggest this might be because in rural areas, there are fewer doctors available, so people value the few services they do have more highly. It's like being willing to pay more for water when you are in a desert than when you are next to a river.
• The Higher Earners: Families with more money in their monthly budget were more willing to contribute.

4. The Big Picture

The study concludes that while people in Eastern Kasai want to pay for healthcare, their ability to do so is shaky. It depends entirely on how much money they have and whether they trust the quality of the care.

The authors suggest that to fix the system, the country needs to build a "safety net" (like insurance or a pre-payment system) so people don't have to pay a huge lump sum when they get sick. But, they also warn that building this net won't work unless the "product" inside it—the healthcare itself—is actually good. If the care is poor, people won't pay for it, no matter how cheap it is.

In short: People are willing to buy a ticket to the health show, but only if the ticket price fits their budget and they believe the show will be worth watching.

Technical Summary

Technical Summary: Willingness to Pay for Primary Health Care Services and Associated Factors in Eastern Kasai, Democratic Republic of the Congo

Problem Statement
The Democratic Republic of the Congo (DRC) faces a critical challenge in health financing, where the system relies heavily on out-of-pocket (OOP) payments, accounting for 91–92% of household health expenditures. Despite economic growth, living standards remain low, and access to quality care is constrained by financial barriers. With declining Official Development Assistance (ODA) and ongoing efforts to achieve Universal Health Coverage (UHC), there is an urgent need to understand the capacity and willingness of households to contribute to health financing. While national projections aim to increase per capita health expenditure, there is limited empirical evidence regarding households' actual willingness to pay (WTP) for primary health care (PHC) services in specific regions like Eastern Kasai, a province characterized by high poverty rates (81.3%) and a heavy reliance on informal economic activities.

Methodology
This study employed a cross-sectional observational design based on the contingent valuation method (CVM) to assess WTP.

• Setting and Population: The study was conducted in Eastern Kasai Province between July 10 and July 30, 2025. The target population consisted of household heads (aged ≥18) responsible for health-related financial decisions.
• Sampling: A multistage probabilistic sampling approach (five-stage) was used to select 633 households. The sample was proportionally distributed across eight health zones (five urban, three rural) based on demographic weight.
• Data Collection: Data were gathered via semi-structured interviews using the KoboToolBox platform on Android devices. The instrument utilized a stated preference approach, presenting respondents with hypothetical cost scenarios for PHC services ranging from free care to levels exceeding 571,000 CDF (approx. USD 250).
• Analysis: Descriptive statistics were used for sociodemographic and clinical characteristics. Logistic regression analysis (Generalized Linear Model framework) was performed using R 4.5.0 to identify factors associated with WTP. Variables with a p-value < 0.25 in bivariate analysis were included in the multivariable model. Significance was set at p < 0.05.

Key Results

• Willingness to Pay: Overall, 70% of household heads expressed willingness to pay for their own health care, and 73% for other household members. However, WTP demonstrated high price sensitivity: it was 95.5% for free care but dropped to 6.3% at the highest cost levels (>230,000 CDF).
• Reasons for Refusal: Poor perceived quality of care was a consistent reason for refusal across all cost levels. At lower costs, unemployment and dissatisfaction with quality were primary drivers. As costs increased, financial constraints (low income, indebtedness) became the predominant reasons for refusal, with "costs too high" emerging as the primary barrier at the highest price points.
• Associated Factors: Multivariable analysis identified three significant predictors of higher WTP:
  1. Professional Activity: Households with a professional activity were nearly twice as likely to be willing to pay (aOR = 1.9; 95% CI: 1.2–3.0).
  2. Rural Residence: Surprisingly, residence in rural health zones was associated with higher WTP compared to urban areas (aOR = 2.1; 95% CI: 1.3–3.7).
  3. Household Income: Higher monthly household income (≥16,426.5 CDF) was significantly associated with WTP (aOR = 2.2; 95% CI: 1.2–4.0).
• Clinical Context: While 34% of households reported medical consultations in the past 12 months (mostly for acute conditions like malaria and typhoid), 36.5% reported hospitalizations. Despite hospitalization costs being relatively low in absolute terms (67.1% under 100,000 CDF), 96.3% of households perceived these costs as "high" or "very high."

Significance and Claims
The paper claims that these findings provide original evidence in a data-scarce context, highlighting that WTP in Eastern Kasai is moderate but highly sensitive to cost and strongly influenced by socioeconomic conditions and perceived service quality. The study underscores that while households are willing to contribute, their capacity is limited by structural poverty and income instability.

The authors assert that the results underscore the necessity of strengthening financial protection mechanisms, specifically through the development of prepayment and risk-pooling systems, rather than relying solely on direct OOP payments. Furthermore, the findings suggest that improving the perceived quality of care is as critical as financial interventions for enhancing health care utilization and progressing toward UHC in the DRC. The study acknowledges limitations regarding potential reporting and strategic biases inherent in contingent valuation but maintains that the consistency of findings with existing literature supports their external validity.