Research Article: Effect of Removing Direct Payment for Health Care on Utilisation and Health Outcomes in Ghanaian Children: A Randomised Controlled Trial

Date Published: January 6, 2009

Publisher: Public Library of Science

Author(s): Evelyn Korkor Ansah, Solomon Narh-Bana, Sabina Asiamah, Vivian Dzordzordzi, Kingsley Biantey, Kakra Dickson, John Owusu Gyapong, Kwadwo Ansah Koram, Brian M Greenwood, Anne Mills, Christopher J. M Whitty, Arachu Castro

Abstract: BackgroundDelays in accessing care for malaria and other diseases can lead to disease progression, and user fees are a known barrier to accessing health care. Governments are introducing free health care to improve health outcomes. Free health care affects treatment seeking, and it is therefore assumed to lead to improved health outcomes, but there is no direct trial evidence of the impact of removing out-of-pocket payments on health outcomes in developing countries. This trial was designed to test the impact of free health care on health outcomes directly.Methods and Findings2,194 households containing 2,592 Ghanaian children under 5 y old were randomised into a prepayment scheme allowing free primary care including drugs, or to a control group whose families paid user fees for health care (normal practice); 165 children whose families had previously paid to enrol in the prepayment scheme formed an observational arm. The primary outcome was moderate anaemia (haemoglobin [Hb] < 8 g/dl); major secondary outcomes were health care utilisation, severe anaemia, and mortality. At baseline the randomised groups were similar. Introducing free primary health care altered the health care seeking behaviour of households; those randomised to the intervention arm used formal health care more and nonformal care less than the control group. Introducing free primary health care did not lead to any measurable difference in any health outcome. The primary outcome of moderate anaemia was detected in 37 (3.1%) children in the control and 36 children (3.2%) in the intervention arm (adjusted odds ratio 1.05, 95% confidence interval 0.66–1.67). There were four deaths in the control and five in the intervention group. Mean Hb concentration, severe anaemia, parasite prevalence, and anthropometric measurements were similar in each group. Families who previously self-enrolled in the prepayment scheme were significantly less poor, had better health measures, and used services more frequently than those in the randomised group.ConclusionsIn the study setting, removing out-of-pocket payments for health care had an impact on health care-seeking behaviour but not on the health outcomes measured.Trial registration: (#NCT00146692).

Partial Text: Levels of mortality in African children are unacceptably high. Access to medical care is a key determinant of health and one that can be addressed [1,2]. Malaria is a major contributor to childhood morbidity and mortality in children under 5 y of age [3]. In most settings where it has been investigated, the majority of children with symptoms compatible with malaria do not access formal health care [4,5]. Delay in seeking care can end in the death of a sick child before or shortly after they reach the clinic; almost all of these deaths should be avoidable if treated early [6]. More commonly, untreated or under-treated malaria can cause significant morbidity, especially anaemia. The same is true for many of the other major diseases of childhood.

A household randomised, controlled unblinded trial of the impact of providing free primary health care, drugs, and initial secondary care on moderate anaemia in Ghanaian children under 5 y of age was undertaken. The study included a third observational arm of those who self-enrolled in a prepayment scheme.

The study ran from May 2004 to February 2005. 2,332 households in Dodowa and Prampram subdistricts with 2,757 children aged 6–59 mo randomly selected from a district database to participate in the trial. No household refused consent. 138 of these households with 165 children had already enrolled voluntarily in the prepayment scheme at the time of closure of the registration window; all agreed to take part in the observational arm. The remainder, 2,194 households with 2,592 children were randomised and included in the trial. A total of 2,524 children from 2,151 households participated in the baseline cross-sectional survey, 1,227 from the intervention and 1,297 from the control arm. 68 children were unavailable due to travel. Follow-up at the final cross sectional study was 92% in the intervention and 93% in the control arms, respectively (Figure 1). Households in the intervention and control arms were similar at baseline (Table 1). However, the self-enrolled group were different from the randomised groups both in socioeconomic and health status at the start of the trial (Table 1). The trial groups were evenly distributed across the wealth quintiles, but the self-enrolled group was skewed toward the wealthier quintiles (Figure 2).

This trial in rural Ghana found that children in households randomised to free healthcare used formal healthcare more and informal healthcare less than a control group. This utilisation did not translate into any change in anaemia (the primary outcome), mortality, or other health outcomes measured. An observational group who had paid to self-enrol into the same scheme were wealthier, healthier, and used both formal and informal healthcare more than those randomised to it at baseline and subsequently. A number of studies in both developed and developing countries have investigated the impact of lowering direct financial barriers to health care on utilisation, but this is the first randomised trial to investigate the impact of providing free health care on health outcomes. It used malaria-associated health outcomes in children as the indicator of health impact as it is the most important cause of serious childhood mortality and morbidity in the area. The failure to find any demonstrable health benefit from the change in utilisation following free health care was demonstrated even for those living within 5 km of a health care facility (so with limited physical barriers to access). This lack of any effect, including on secondary outcomes such as Hb for which the study had good power, challenges the assumption that where introducing free health care leads to changes in utilisation, it can safely be assumed to translate into health benefits. Given the potential size of resources involved in providing free health care that could be diverted from other priorities on the basis of that assumption, this finding is potentially important for policymakers.



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