The World Report on Disability estimated that 15% of the global population, equating to around one billion persons, live with some form of disability, 80% of whom are in low- and middle-income countries (LMICs) (World Health Organization [WHO] 2011). These persons with disabilities (PWDs) have long-term physical, mental, intellectual or sensory impairments which, in interaction with various barriers, may hinder their full and effective participation in society on an equal basis with others (United Nations n.d.). Despite the progress made in recent years, PWDs continue to face discrimination and stigma on the grounds of disability, a lack of access to physical environments, assistive devices and essential rehabilitation services, and a lack of support for independent living (WHO 2018). They are often excluded from education, health, and employment and other aspects of society, leading to an increased risk of poverty (WHO 2011).

Following the Declaration of Alma-Ata in 1978, the WHO endorsed the concept of community-based rehabilitation (CBR) to enhance the quality of life of PWDs through multisectoral disability prevention and rehabilitation. Since 2006, CBR is guided by a matrix across five components: health, education, livelihood, empowerment and socialisation. Under each component, there are five elements, each implemented through specific activities (WHO 2010).

Democratic Republic of Congo (DRC) is a low-income country in sub-Saharan Africa. An estimated 10.5 million (11%) of the country’s 96 million population have one or more disabilities, the result of disease and illness, genetic and chromosomal conditions, poverty and a weak healthcare system as well as ongoing conflict (Street Child 2018; WHO 2011). The government of DRC has taken several measures to protect PWDs, including adopting a disability policy in 2010, ratifying the United Nations Convention on the Rights of Persons with Disabilities in 2015, enshrining the rights of PWDs in the Constitution and endorsing a CBR strategy, which is to be implemented by the Ministry of Health by health zones (Ministry of Health n.d.). Despite these developments, ongoing internal conflict, corruption and other challenges have limited the government’s ability to provide accessible and affordable services for PWDs, and various non-governmental organisations (NGOs) such as Humanity and Inclusion, International Committee of the Red Cross, and Fédération Nationale des Associations Des Personnes Vivant Avec Handicap Du Congo (FENAPHACO) have stepped in to help fill the gap, though these service offerings are often fragmented in nature (Street Child 2018).

In the Uvira health zone of South Kivu province of eastern DRC, Appui au Développement de l’Enfant en Detresse (ADED), a local NGO, has been facilitating the implementation of a disability prevention and rehabilitation programme under the name ‘Tunafasi’ in partnership with the local health zone and with initial financial support from a private foundation in the Netherlands. The programme’s overall aim is to enable a positive environment, sustainable autonomy and equal opportunity for PWDs under the age of 33 years and their communities through the integration of the CBR programme in the state system and with community contributions. The programme is based on the CBR matrix and modelled after the Inspire2Care disability prevention and rehabilitation programme, implemented by the Karuna Foundation in Nepal, a Nepali NGO (Karuna Foundation Nepal n.d.). Tunafasi has brought together a number of organisations and service centres that previously provided fragmented services for PWDs in Uvira, including Sosame (mental health services), Centre Bethanie (physical rehabilitation), Haki Yetu, Center d’éducation et formation intégré (CEFI) and Center la Providence des Sourds d’Uvira (CEPROS) and ADED in a network called Muungano Tegemeza. With initial support from Liliane Fonds, ADED and network partners worked together to expand the range of services offered to encapsulate activities across all five CBR pillars (Muungano Tegemeza Network 2023). Together with 22 CBR facilitators (CBRFs), who are government employees with a background in nursing and work at 22 different health facilities, ADED officers facilitate the implementation of the programme (ADED 2020).

Disability prevention activities focus on strengthening maternal and child healthcare in the public health centres through training and equipment support and creating demand for services through awareness raising. Rehabilitation activities are based on the CBR matrix and are customised to address the unique needs of each PWD. Upon their identification, each PWD is assessed by a multidisciplinary team of doctors, physiotherapists, psychologists and other experts, after which an individual rehabilitation plan is jointly developed together with the PWD, his or her family and the CBRF. With the support from ADED officers, the CBRFs make home visits, provide counselling to PWDs and their families, provide physiotherapy or orient parents on it, facilitate medical treatment of PWDs from local health centres, hospitals or referral service centres and link them with local resources. Medical rehabilitation may include counselling, physiotherapy, medical treatment, assistive devices, nutrition support and/or referral medical services. The rehabilitation elements under other pillars range from tuition fee support, home-based education, self-help groups, vocational training, saving and credit activities and more. The programme equally works to strengthen the public system (health zone, health centre, schools) as well as the community support system like self-help groups, organisations of PWDs and child clubs. Community-based rehabilitation facilitators are currently paid by government, while ADED officers and other programme costs are supported by private investors from the Netherlands. There are plans to fully transition programme funding and implementation to the government and the community within 5 years (ADED 2020). With the start of the Tunafasi programme, Uvira became the only health zone in the country known to be implementing all five CBR pillars (though as of early 2023 Tunafasi has now expanded to Baraka and Goma health zones). Six other health zones in South Kivu are known to be implementing the health pillar only; for the country as a whole, 37 out of the country’s 517 health zones are known to be implementing the health pillar only.

Globally, the coverage of CBR is currently very low and there is a lack of available evidence about its effectiveness and cost-effectiveness (Iemmi et al. 2013), partially because of methodological challenges related to evaluating across five distinct domains (Shumba, Haufiku & Mitonga 2020). There are also perceptions that health services for PWDs are unaffordable for governments, though methods do exist for assessing the cost, cost-effectiveness and affordability of the health component, particularly medical rehabilitation services (United Nations n.d.; Vaughan & Thapa 2015).

As part of efforts to encourage rollout of the CBR strategy in other government health zones, Tunafasi donors commissioned a cost-effectiveness evaluation and affordability assessment of the first 2 years of implementation of the programme’s medical rehabilitation component. The assessment aimed to generate evidence to support advocacy efforts with the government health zone and community structures about the affordability of medical rehabilitation integrated in the primary healthcare system.

The study evaluated the economic efficiency of a newly implemented collaboration between regional health authorities and a local NGO to improve the provision of medical rehabilitation services for PWDs in Uvira, DRC. This study evaluated the costs, DALYs averted and cost per DALY averted of the programme to assess the feasibility of long-term continuation of the programme without external funding as part of the government’s primary healthcare system.

This study estimated that the programme spent $55 729.00 to assess and provide medical rehabilitation services to 511 PWDs, which resulted in 234 DALYs averted at a cost per DALY averted of $224.00. There is little research done on the cost per DALY averted of medical rehabilitation services for PWDs which can offer a comparison. A previous study was conducted in Nepal of a similar disability rehabilitation programme, which found a cost per DALY averted of €384.00 – €843.00 (approx. $335.00 – $735.00) (Vaughan et al. 2018). However, this assessment used earlier GBD DWs and included more adults, for whom fewer DALYs are often averted due to their shorter remaining lifespans. Therefore, it is hard to directly compare the two studies.

Previously, it was common to use a threshold defined as three times gross domestic product (GDP) per capita as a guide to determining the cost-effectiveness of health interventions. However, this specific threshold approach has fallen out of use after multiple criticisms over its failure to consider local resource availability (Bertram et al. 2016; Leech et al. 2018; Robinson et al. 2016). Two alternatives to assess affordability include comparing against a benchmark intervention already offered by the health system (but there are no known comparators for DRC), and country-specific cost per DALY averted thresholds that reflect health opportunity costs. There are currently two such thresholds for DRC. Ochalek and colleagues used estimated elasticities on mortality, survival, morbidity and DALYs, while also taking into account infrastructure, changes in donor funding, country-specific data on health expenditure, epidemiology and demographics, to estimate a threshold of $54.00 – $69.00 per DALY averted (2015 US$, approx. $62.00 – $79.00 in 2021), which is only 12% – 15% of the GDP per capita for DRC (Ochalek, Lomas & Claxton 2018). A similar approach was used by Daroudi and colleagues, who used evidence from the GBD study, per capita health expenditure, human development index (HDI) score and GDP per capita for 176 countries over the period 2000 to 2016 (Daroudi et al. 2021). They found the threshold cost per DALY averted was, on average, 0.34 times the GDP per capita in low HDI countries like DRC. This would equate to an approximate threshold of $199.00, based on the 2021 GDP per capita of $584, in our setting. Our cost per DALY averted estimate of $224 is above both thresholds, but still lower than roughly half of other interventions implemented in LMIC settings (Horton 2018). It is also important to note that while cost-effectiveness and affordability are important from an economic standpoint, value of particular interventions and their incorporation in, for example, essential health benefit packages guaranteed by government is normally guided by a wider range of criteria, among others, burden of disease, equity and feasibility (Hayati et al. 2018; Horton 2018). Guaranteeing these services despite their cost per DALY averted falling above affordability thresholds would be a timely operationalisation of the June 2022 law which aims to better promote and protect the rights of PWDs (UNCRPD Fund n.d.).

Although some exceptional cases will likely still require outside support to treat in the future, this study has shown that the majority of PWDs can receive medical rehabilitation services from government in a cost-effective way. The innovative implementation of this programme, through the government’s primary healthcare system and with initial, limited-term external financial support from investors in the Netherlands, offers a promising alternative to the more traditional model of fragmented rehabilitation activities implemented by various NGOs, often in parallel with government efforts. However, lobbying and advocacy efforts with the government are needed to ensure a financial commitment to fully finance medical rehabilitation when external support ends, which can be secured by tapping into government funding envelopes specifically available for vulnerable populations. Health spending in DRC is among the lowest in the world, both as a total ($19.69 per capita in 2018 [2020 US$]) and in terms of government’s contribution ($2.62 per capita [13%]) (The World Bank n.d.). Given the population of Uvira (387 421), the Tunafasi programme costs approximately $0.14 per person per year, of which the government’s share is presently 5.3% or less than $0.01 per person per year. Local authorities can already start taking over an increasing share of costs of and responsibility for the programme by increasing the level of effort of the part-time CBRFs and providing them with necessary training and financial as well as non-financial motivation.

Community-based rehabilitation programmes are traditionally challenging to evaluate, namely because of their breadth across health, education, livelihoods, empowerment and social aspects (Hartley 2016). Our study has focused on costs and health-related gains of medical rehabilitation services, given the existence and suitability of the DALY as a metric for measuring improvements as a result of medical rehabilitation. We also chose to focus on medical rehabilitation given the need to assess the long-term affordability of the programme in terms that can be easily understood by the Ministry of Health, given that CBR is housed in the Ministry of Health in DRC and the DALY is the most common outcome measure for health services in LMICs. However, we have not captured some of the major benefits stemming from CBR programmes’ four other pillars, such as increased community mobilisation around disability, skills gained by the members of families of PWDs, improvements in attitudes of community members towards PWDs and social cohesion. This is an important limitation of our study (Vaughan et al. 2018).

Medical rehabilitation services can be affordable for government in LMIC settings such as DRC and represent good value for money at a cost per DALY averted of $224.00. The implementation and funding model presented in this article, through the government’s primary healthcare system and with initial external financial support from investors, can be considered for replication in other LMICs.