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

BackgroundDuring 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.MethodsUsing 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.FindingsOverall, 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