The effects of reducing the direct cost of care on health services utilization and health outcomes in Ghana: a randomized controlled trial

EVELYN KORKOR ANSAH

ICIUM 2011, TURKEY

Background Direct cost of health care is a major barrier to care

and potentially one of the most modifiable Mechanisms aimed at reducing the direct cost of

care have been instituted in many countries. However, direct evidence that reducing financial

barriers has a positive impact on health outcomes is limited.

Observational studies, which tend to be carried out may be subject to many potential biases.

This trial aimed to assess the impact of reducing barrier due to direct cost of care on malaria-associated health outcomes

ICIUM 2011, TURKEY

Study Questions Will increased household financial access

to health care lead to increased health service utilization ?

Will this result in improved health outcomes ?

ICIUM 2011, TURKEY

Study Setting Dangme West District in

Ghana Rural, with scattered

settlements and wide spread poverty

A district wide pre-payment scheme was in its 5th year of operation

People enrolled entitled to all primary care free, incl. drugs. Also, free hospital care up to a ceiling

Adidome

Dangbe West

AsuogyamanManya Krobo

Yilo Krobo

Dangbe East

Akwapim North

Tema Municipal AreaGulf of Guinea

Ningo

Osudoku

Dodowa

Prampram

28064

18972

30872

22845

10 0 10 20 Kilometers

Ghana N

Dangme West District

Sub-districts of DWD

Dangme West District

ICIUM 2011, TURKEY

Study Design A two-arm randomized controlled unblinded

trial. The HH was the unit of randomization All HH not yet enrolled in the scheme at time of

closure of enrolment window with chn 6-59 mths eligible. Simple random sample

A baseline HH survey of 2,151 HH with 2,524 chn 6-59 mths carried out post randomization

Followed by a 6-mth period of passive morbidity monitoring

Final HH cross-sectional survey was carried out at end of 6-mth period

ICIUM 2011, TURKEY

Intervention Members of HHs in intervention arm were

enrolled into the existing pre-payment scheme which provided the following benefits: Individual photo-IDs which allowed free

unlimited access to primary care at any of the 10 clinics PLUS secondary care up to a US$45 ceiling in any of 5 hospitals of their choice

Members of HH in the control grp paid for their health care out of pocket with promise of equivalent benefit the ff yr

HHs could not change their grp till study endICIUM 2011, TURKEY

Screening, enrollment and randomization

Allocation to the two arms was by simple randomization (community ballot) stratified by distance {<5km, 5-10km, >10km}

This was to ensure community acceptance

ICIUM 2011, TURKEY

Follow-up - Passive Morbidity monitoring by pictorial diary method with avg. 7.5% LFUP

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Final Cross-sectional survey

ICIUM 2011, TURKEY

Comparability of groups at baseline- demographics, outcomes, malaria prevention, wealth quintiles

0

5

10

15

20

25

30

35

Proportion (%)

Poorest Very Poor Poor Less Poor Least Poor

Wealth Quintiles

Distribution of wealth quintiles in study arms

Control

Intervention

Self-enrolled

ICIUM 2011, TURKEY

Results- Utilization of healthcare

Visits/person- year

Control

n=1197

Intervention

n=1124

p-value 95% CI

Primary Care Clinic

2.50 2.80 0.001 1.04-1.20

Chemical seller

2.97 2.69 <0.003 0.85-0.97

Home Treatment

2.01 1.79 0.005 0.82-0.96

Non-formal care

5.10 4.59 <0.001 0.86-0.95

ICIUM 2011, TURKEY

Results: Utilization of Informal sector care Among the intervention group, use of

informal care was significantly lower among those living close to the health facility

But, as distance from HF increased, informal sector use increased among both control and intervention groups

Gates Malaria Partnership

Results- Health outcomesControl

n=1197

Intervention

n=1124

p-value

Hb<8g/dl (%) 37 (3.1) 36 (3.2) 0.88

Hb<6g/dl (%) 3 (0.25) 2 (0.2) 0.71

Mean Hb 11.0 11.1 0.47

Mean change Hb

+0.71 +0.75 0.69

Deaths 4 5 0.67

ICIUM 2011, TURKEY

Primary outcome: effect on moderate anaemia (Hb<8g/dl)

OR (95% CI) p-value

Crude 1.04 (0.65-1.65) 0.877

Adjusted for age, sex, distance, poverty, clustering

1.05 (0.66–1.67) 0.837

ICIUM 2011, TURKEY

Lessons learnt Those who enrol voluntarily in pre-payment

schemes are significantly different from those who do not.

Non-randomized study designs may suffer from bias as a result of this

Improved financial access led to significant change in healthcare use but not in measured health outcomes

Non-financial barriers (such as distance) are important influences in care-seeking in this setting

Policy Implications & Research Gap

Policy implication There is a need to find innovative ways to

remove non-financial barriers to health care in order to ensure real access to those who really need it

Research Gap Need to consider randomized designs in

evaluating the effect of health financing interventions in other settings

ICIUM 2011, TURKEY

AcknowledgementsFunding by Gates Malaria Partnership, LSHTM

LSHTM, UK Prof. Richard Hayes Prof Brian Greenwood Prof Anne Mills Prof. Christopher

Whitty

Noguchi Memorial Institute for Medical Research, Ghana

Mr. Kakra Dickson Prof. Kwadwo Koram

Ghana Health Service Mr. Solomon Narh-Bana Mr. Kingsley Biantey Mrs. Sabina Asiamah Ms. Vivian Dzordzordzi Prof. John Gyapong Dr. Margaret Gyapong Prof Irene Agyepong Acad. Med. Centre Netherlands Dr. Teunnis Eggelte

ICIUM 2011, TURKEY