Date Published: January 6, 2009
Publisher: Public Library of Science
Author(s): Valéry Ridde, Slim Haddad
Abstract: Valéry Ridde and Slim Haddad discuss a new trial in Ghana in which households were randomized into a pre-payment scheme allowing free primary care or to a control group who paid user fees for health care.
Partial Text: In its 2008 annual report, the World Health Organization (WHO) urged countries to “resist the temptation to rely on user fees” [1, p. 26]. Indeed, the consensus in the scientific community is that user fees have harmful effects on health care use and household budgets, especially for the poorest . Still, as the WHO observes, “…most of the world’s health-care systems continue to rely on the most inequitable method for financing health-care services: out-of-pocket payments by the sick or their families at the point of service” [1, p. 24].
Ansah and colleagues’ study did not examine wide-scale national experiences of abolishing user fees, as happened in countries such as Niger and Uganda. Rather, the study was a pilot project on free access to a prepayment scheme in the Dangme West District in southern Ghana. In the trial, 2,194 households containing 2,592 Ghanaian children under five years old were randomised into a pre-payment scheme allowing free primary care, or into a control group whose families paid user fees for health care (normal practice). The study also included an observational arm made up of 165 children whose families had previously paid to enrol in the pre-payment scheme. The primary outcome was moderate anaemia (haemoglobin [Hb] < 8 g/dl); secondary outcomes were health care utilisation, severe anaemia, and mortality. The main strength of Ansah and colleagues' new study is in the choice of an experimental design to assess the impact of pre-payment schemes. There is, in fact, a considerable gap between the enthusiasm generated by pre-payment schemes and the scientific evidence to support their use. Most of the published evaluations are based on observational studies that are not very robust . We are aware of only three studies to date that are based on sound experimental designs [7–9]. In a context of scarce resources, it is essential that interventions be chosen based on conclusive evidence and that outcome evaluations be based on robust designs. But the evaluation of a complex programme such as a prepayment scheme, which has multiple objectives and consequences, cannot be based on an analysis limited to one main outcome. Rather, it requires mobilisation of an array of indicators that can elucidate this complexity and the different causal pathways it puts into play . In that case, a description of the intervention's theory is indispensable . The contribution of qualitative analyses , or of evaluation designs that also take the intervention's context into consideration, should also not be overlooked [15,16]. Finally, it is imperative that outcome evaluation be combined with process evaluation. This allows us, particularly, to assess any implementation deficits (type III evaluation errors) . Ansah and colleagues' study and the emerging literature on the effects of abolishing user fees in Africa  show that lowering financial barriers could promote utilisation of health services, as claimed by the WHO Commission on the Social Determinants of Health . But the decision to abolish fees is not enough. People's trust in their health care services must be restored, and investments (such as salaries and drugs) must be made to improve the service offered. While it is clear fees must be abolished, how to accomplish this is not really known. It is also urgent to evaluate processes, unintended effects, and the actions of those involved in implementation [20,21]. Source: http://doi.org/10.1371/journal.pmed.1000008