Impact of a free care policy on routine health service volumes during a protracted Ebola virus disease outbreak in the Democratic Republic of Congo

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Department of International Health and Sustainable Development, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St. Suite 2200, New Orleans, Louisiana, USA
University of Kinshasa School of Public Health, Faculty of Medicine, Kinshasa, Congo

Received 8 March 2022, Revised 2 February 2023, Accepted 28 February 2023, Available online 1 March 2023.



In response to the DRC’s 10th Ebola Virus Disease (EVD) outbreak, the government subsidized routine health services in select health zones with the goal of maintaining routine service volumes. We assess the impact of the initial and revised Free Care Policies (FCP) on total clinic visits, uncomplicated malaria, simple pneumonia, fourth antenatal care clinic visits, and measles vaccinations, testing the hypothesis that routine services would not significantly decrease during the FCP.

Methods and findings

We used data from the DRC’s national health information system spanning January 2017 to November 2020. Intervention facilities were those that were initially and secondarily enrolled in the FCP, which occurred in August 2018 and November 2018, respectively. Comparison facilities were limited to the North Kivu Province and were from health zones that recorded at least one case of Ebola. A controlled interrupted time series analysis was conducted. The FCP appeared to have a positive effect in increasing overall clinic attendance rates, uncomplicated malaria case rates, and simple pneumonia case rates in those health zones where the policy was enacted relative to comparison sites. The longer-term effects of the FCP were mostly non-significant or, if significant, relatively modest in nature. Rates for measles vaccinations and fourth ANC clinic visits appeared to be unaffected or minimally affected, respectively, by the implementation of the FCP and relative to comparison sites. We did not observe the decrease in measles vaccinations that has been observed elsewhere. The study is limited in that we were unable to account for health facility bypassing and service volumes at private health facilities.


Our findings provide evidence that FCPs can be used to maintain routine service provision during outbreaks. Additionally, the study design demonstrates that routinely reported health information from the DRC are sensitive enough to detect changes in health policy.


Demand for health care
Health economics
Health policy and planning
Infectious diseases/communicable diseases
Primary care
Time series analysis
Democratic Republic of the Congo