Removing user fees does not improve health outcomes in Ghana

Removing user fees for primary health care changed health utilization behaviour but did not improve health outcomes among households with children under the age of five in Ghana, says a new study published in the open access journal PLoS Medicine.

Evelyn Ansah and colleagues from the London School of Hygiene & Tropical Medicine and the University of Ghana, randomised 2,194 households containing 2,592 Ghanaian children under 5 years of age into either a prepayment scheme providing free primary care including drugs, or to a control group paying user fees for health care, which was normal practice in the region. Introducing free primary health care changed the health care seeking behaviour of households: those not paying user fees used formal health care more and nonformal care less than those who did pay user fees.

However, introducing free primary health care did not result in—as is often assumed—improved health outcomes. Similar proportions (3.1% and 3.2%) of children were found to have moderate anemia in both groups, and the number of deaths among children were similar. Mean hemoglobin (Hb) concentration, severe anemia, parasite prevalence, and anthropometric measurements were similar, no matter whether user fees were paid or not.

The authors say their trial’s findings are important because most researchers and policymakers assume that free health care leads to better health outcomes. “This lack of any effect, including on secondary outcomes such as Hb for which the study had good power,” the authors say, “challenges the assumption that where introducing free health care leads to changes in utilisation, it can safely be assumed to translate into health benefits.”

However, the authors acknowledge that there remain equity arguments for providing free healthcare and there may be unmeasured effects of removing out of pocket payments on children’s health. It may be that increases in health care utilization in the intervention arm compared to the control arm were too modest to produce a clear effect on health, or that in Ghana the indirect costs of seeking health care may be more important than the direct cost of paying for treatment, the authors say.

In an expert commentary on the research, Valéry Ridde and Slim Haddad (Université de Montréal, Quebec, Canada), who were uninvolved in the study, say that the study is timely, “since most international funding agencies seem prepared to support African states that remove user fees.” Ridde and Haddad discuss the implications of the study findings for public health and for future research on user fees.
Source: PLoS Medicine

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