Free Maternal and Neonatal Care in Urban DRC: Effects on Service Utilization and Implementation Challenges in Kinshasa

Technical Summary: Free Maternal and Neonatal Care in Urban DRC

Problem Statement
Despite global progress, maternal and neonatal mortality remain critical public health challenges, particularly in sub-Saharan Africa, where out-of-pocket payments frequently act as barriers to care-seeking. While many nations have introduced user fee removal policies to advance Universal Health Coverage (UHC), evidence regarding their implementation dynamics and effectiveness in large, heterogeneous urban settings remains limited. In the Democratic Republic of Congo (DRC), maternal and neonatal mortality rates are among the highest in the region. In 2023, the Congolese government implemented a policy providing free maternal and neonatal care, including antenatal care, deliveries, caesarean sections, and essential medicines. However, this policy was introduced into a health system already constrained by human resource shortages, medicine stock-outs, and limited service capacity. There is a need to rigorously evaluate whether this policy successfully increased service utilization in Kinshasa and to understand the organizational mechanisms that facilitate or hinder its implementation.

Methodology
The study employs a mixed-methods quasi-experimental design to evaluate the policy's impact in Kinshasa between January 2021 and September 2025.

• Quantitative Component:

  • Data Source: Routine health facility data extracted from the National Health Information System (NHIS).
  • Sample: A longitudinal panel of 74 health facilities (public, faith-based, and private) across four health zones. Facilities were categorized as "supported" (enrolled in the free care program) or "non-supported" (comparison group).
  • Design: A 1:1 matching strategy was used to pair supported facilities with non-supported facilities based on legal status, level of care, and baseline service volume.
  • Analysis: A Difference-in-Differences (DiD) model with facility and year fixed effects was utilized to estimate the causal effect of the policy. The model compared trends in service utilization between the two groups before (2021–2022) and after (2023–2025) the policy implementation. Robust standard errors were clustered at the facility level. An event-study specification was used to validate the parallel trends assumption.
  • Outcomes: Primary outcomes included institutional deliveries, antenatal care visits (ANC1 and ANC4), postnatal care visits (PNC1–PNC3), caesarean sections, and mortality rates (maternal and neonatal).

• Qualitative Component:

  • Data Collection: Purposive sampling was conducted in seven facilities (three supported, four non-supported). Semi-structured interviews were conducted with 14 participants (seven healthcare providers and seven service users).
  • Analysis: Thematic analysis was performed using NVivo 15, guided by the Penchansky and Thomas framework on access to care and Andersen's behavioral model of health service use.
  • Integration: Quantitative and qualitative findings were triangulated to interpret the mechanisms driving observed utilization trends.

Key Contributions and Results

• Impact on Service Utilization:
  The DiD analysis reveals that the free care policy was associated with substantial and statistically significant increases in service utilization in supported facilities compared to non-supported facilities. Specifically, the policy led to annual increases per facility of:

  • Approximately 297 institutional deliveries.
  • 269 first antenatal care visits (ANC1).
  • 125 complete antenatal care visits (ANC4).
  • Between 200 and 289 postnatal consultations.
  • Increases in essential neonatal care and live births were also significant.
  • The effect on caesarean sections was positive but more modest (+25 procedures).

• Mortality Outcomes:
  The study found no statistically significant impact on maternal mortality or neonatal mortality in the short term. The authors note that maternal mortality is a rare event at the facility-year level, and the study period may be insufficient to detect short-term mortality reductions, which often require improvements in care quality beyond mere access.

• Implementation Challenges (Qualitative Findings):
  While the removal of fees successfully reduced financial barriers and stimulated demand, qualitative data highlighted significant organizational constraints:

  • Partial Free Care: Medicine stock-outs frequently forced patients to purchase drugs out-of-pocket, reintroducing financial barriers.
  • Overcrowding and Staff Shortages: Increased demand led to severe overcrowding and workload pressures without commensurate increases in staffing or infrastructure.
  • Quality Concerns: Users and providers reported concerns regarding the quality of care, with some users associating free facilities with less attentive care, influencing their choice of facility.

Significance and Claims
The paper claims that free maternal and neonatal care can rapidly and effectively increase service utilization in urban settings, acting as a powerful lever to stimulate demand and reduce financial barriers. However, the study emphasizes that financial access alone is insufficient to translate increased utilization into sustainable improvements in severe health outcomes like mortality.

The authors conclude that the policy's effectiveness is tightly linked to the broader health system's capacity. Without parallel investments in the workforce, supply chains, and service organization, fee removal risks creating a surge in demand that overwhelms existing infrastructure, potentially compromising the quality of care. Therefore, the paper argues that user fee removal policies must be accompanied by strategic resource allocation to ensure system sustainability and performance. The study underscores the necessity of mixed-methods approaches to capture both the quantitative success of access expansion and the qualitative realities of implementation bottlenecks.