Effect of Removing Direct Payment for Health Care on Utilisation and Health Outcomes in Ghanaian Children: A Randomised Controlled Trial
Identifieur interne : 000A29 ( Main/Exploration ); précédent : 000A28; suivant : 000A30Effect of Removing Direct Payment for Health Care on Utilisation and Health Outcomes in Ghanaian Children: A Randomised Controlled Trial
Auteurs : Evelyn Korkor Ansah [Royaume-Uni, Ghana] ; Solomon Narh-Bana [Ghana] ; Sabina Asiamah [Ghana] ; Vivian Dzordzordzi [Ghana] ; Kingsley Biantey [Ghana] ; Kakra Dickson [Ghana] ; John Owusu Gyapong [Royaume-Uni] ; Kwadwo Ansah Koram [Ghana] ; Brian M. Greenwood [Royaume-Uni] ; Anne Mills [Royaume-Uni] ; Christopher J. M. Whitty [Royaume-Uni]Source :
- PLoS Medicine [ 1549-1277 ] ; 2009.
Abstract
Delays 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.
2,194 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.
In 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: ClinicalTrials.gov (
Url:
DOI: 10.1371/journal.pmed.1000007
PubMed: 19127975
PubMed Central: 2613422
Affiliations:
- Ghana, Royaume-Uni
- Angleterre, Grand Londres, Région du Grand Accra
- Accra, Legon (Ghana), Londres
- Université du Ghana
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wicri:level="3"><nlm:aff id="aff1"> London School of Hygiene & Tropical Medicine, London, United Kingdom</nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea> London School of Hygiene & Tropical Medicine, London</wicri:regionArea><placeName><settlement type="city">Londres</settlement><region type="country">Angleterre</region><region type="région" nuts="1">Grand Londres</region></placeName></affiliation><affiliation wicri:level="1"><nlm:aff id="aff2"> Dangme West District Health Directorate, Dodowa, Ghana</nlm:aff><country xml:lang="fr">Ghana</country><wicri:regionArea> Dangme West District Health Directorate, Dodowa</wicri:regionArea><wicri:noRegion>Dodowa</wicri:noRegion></affiliation></author><author><name sortKey="Narh Bana, Solomon" sort="Narh Bana, Solomon" uniqKey="Narh Bana S" first="Solomon" last="Narh-Bana">Solomon Narh-Bana</name><affiliation wicri:level="1"><nlm:aff id="aff2"> Dangme West District Health Directorate, Dodowa, Ghana</nlm:aff><country xml:lang="fr">Ghana</country><wicri:regionArea> Dangme West District Health Directorate, Dodowa</wicri:regionArea><wicri:noRegion>Dodowa</wicri:noRegion></affiliation></author><author><name sortKey="Asiamah, Sabina" sort="Asiamah, Sabina" uniqKey="Asiamah S" first="Sabina" last="Asiamah">Sabina Asiamah</name><affiliation wicri:level="1"><nlm:aff id="aff2"> Dangme West District Health Directorate, Dodowa, Ghana</nlm:aff><country xml:lang="fr">Ghana</country><wicri:regionArea> Dangme West District Health Directorate, Dodowa</wicri:regionArea><wicri:noRegion>Dodowa</wicri:noRegion></affiliation></author><author><name sortKey="Dzordzordzi, Vivian" sort="Dzordzordzi, Vivian" uniqKey="Dzordzordzi V" first="Vivian" last="Dzordzordzi">Vivian Dzordzordzi</name><affiliation wicri:level="1"><nlm:aff id="aff2"> Dangme West District Health Directorate, Dodowa, Ghana</nlm:aff><country xml:lang="fr">Ghana</country><wicri:regionArea> Dangme West District Health Directorate, Dodowa</wicri:regionArea><wicri:noRegion>Dodowa</wicri:noRegion></affiliation></author><author><name sortKey="Biantey, Kingsley" sort="Biantey, Kingsley" uniqKey="Biantey K" first="Kingsley" last="Biantey">Kingsley Biantey</name><affiliation wicri:level="1"><nlm:aff id="aff2"> Dangme West District Health Directorate, Dodowa, Ghana</nlm:aff><country xml:lang="fr">Ghana</country><wicri:regionArea> Dangme West District Health Directorate, Dodowa</wicri:regionArea><wicri:noRegion>Dodowa</wicri:noRegion></affiliation></author><author><name sortKey="Dickson, Kakra" sort="Dickson, Kakra" uniqKey="Dickson K" first="Kakra" last="Dickson">Kakra Dickson</name><affiliation wicri:level="4"><nlm:aff id="aff3"> Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana</nlm:aff><country xml:lang="fr">Ghana</country><wicri:regionArea> Noguchi Memorial Institute for Medical Research, University of Ghana, Legon</wicri:regionArea><orgName type="university">Université du Ghana</orgName><placeName><settlement type="city">Accra</settlement><settlement type="town">Legon (Ghana)</settlement><region type="region">Région du Grand Accra</region></placeName></affiliation></author><author><name sortKey="Gyapong, John Owusu" sort="Gyapong, John Owusu" uniqKey="Gyapong J" first="John Owusu" last="Gyapong">John Owusu Gyapong</name><affiliation wicri:level="3"><nlm:aff id="aff1"> London School of Hygiene & Tropical Medicine, London, United Kingdom</nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea> London School of Hygiene & Tropical Medicine, London</wicri:regionArea><placeName><settlement type="city">Londres</settlement><region type="country">Angleterre</region><region type="région" nuts="1">Grand Londres</region></placeName></affiliation></author><author><name sortKey="Koram, Kwadwo Ansah" sort="Koram, Kwadwo Ansah" uniqKey="Koram K" first="Kwadwo Ansah" last="Koram">Kwadwo Ansah Koram</name><affiliation wicri:level="4"><nlm:aff id="aff3"> Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana</nlm:aff><country xml:lang="fr">Ghana</country><wicri:regionArea> Noguchi Memorial Institute for Medical Research, University of Ghana, Legon</wicri:regionArea><orgName type="university">Université du Ghana</orgName><placeName><settlement type="city">Accra</settlement><settlement type="town">Legon (Ghana)</settlement><region type="region">Région du Grand Accra</region></placeName></affiliation></author><author><name sortKey="Greenwood, Brian M" sort="Greenwood, Brian M" uniqKey="Greenwood B" first="Brian M" last="Greenwood">Brian M. Greenwood</name><affiliation wicri:level="3"><nlm:aff id="aff1"> London School of Hygiene & Tropical Medicine, London, United Kingdom</nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea> London School of Hygiene & Tropical Medicine, London</wicri:regionArea><placeName><settlement type="city">Londres</settlement><region type="country">Angleterre</region><region type="région" nuts="1">Grand Londres</region></placeName></affiliation></author><author><name sortKey="Mills, Anne" sort="Mills, Anne" uniqKey="Mills A" first="Anne" last="Mills">Anne Mills</name><affiliation wicri:level="3"><nlm:aff id="aff1"> London School of Hygiene & Tropical Medicine, London, United Kingdom</nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea> London School of Hygiene & Tropical Medicine, London</wicri:regionArea><placeName><settlement type="city">Londres</settlement><region type="country">Angleterre</region><region type="région" nuts="1">Grand Londres</region></placeName></affiliation></author><author><name sortKey="Whitty, Christopher J M" sort="Whitty, Christopher J M" uniqKey="Whitty C" first="Christopher J. M" last="Whitty">Christopher J. M. Whitty</name><affiliation wicri:level="3"><nlm:aff id="aff1"> London School of Hygiene & Tropical Medicine, London, United Kingdom</nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea> London School of Hygiene & Tropical Medicine, London</wicri:regionArea><placeName><settlement type="city">Londres</settlement><region type="country">Angleterre</region><region type="région" nuts="1">Grand Londres</region></placeName></affiliation></author></analytic><series><title level="j">PLoS Medicine</title><idno type="ISSN">1549-1277</idno><idno type="eISSN">1549-1676</idno><imprint><date when="2009">2009</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec id="st1"><title>Background</title><p>Delays 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.</p></sec><sec id="st2"><title>Methods and Findings</title><p>2,194 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.</p></sec><sec id="st3"><title>Conclusions</title><p>In 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.</p><p>Trial registration: ClinicalTrials.gov (<ext-link ext-link-type="uri" xlink:href="http://clinicaltrials.gov/ct2/show/NCT00146692">#NCT00146692</ext-link>).</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Jamison, Dtsm" uniqKey="Jamison D">DTSM Jamison</name></author><author><name sortKey="Wang, J" uniqKey="Wang J">J Wang</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Black, Re" uniqKey="Black R">RE Black</name></author><author><name sortKey="Morris, Ss" uniqKey="Morris S">SS 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Afari</name></author><author><name sortKey="Koram, Ka" uniqKey="Koram K">KA Koram</name></author><author><name sortKey="Ahorlu, Ck" uniqKey="Ahorlu C">CK Ahorlu</name></author><author><name sortKey="Abubakar, I" uniqKey="Abubakar I">I Abubakar</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Csete, J" uniqKey="Csete J">J Csete</name></author></analytic></biblStruct></listBibl></div1></back></TEI><affiliations><list><country><li>Ghana</li><li>Royaume-Uni</li></country><region><li>Angleterre</li><li>Grand Londres</li><li>Région du Grand Accra</li></region><settlement><li>Accra</li><li>Legon (Ghana)</li><li>Londres</li></settlement><orgName><li>Université du Ghana</li></orgName></list><tree><country name="Royaume-Uni"><region name="Angleterre"><name sortKey="Ansah, Evelyn Korkor" sort="Ansah, Evelyn Korkor" uniqKey="Ansah E" first="Evelyn Korkor" last="Ansah">Evelyn Korkor Ansah</name></region><name sortKey="Greenwood, Brian M" sort="Greenwood, Brian M" uniqKey="Greenwood B" first="Brian M" last="Greenwood">Brian M. Greenwood</name><name sortKey="Gyapong, John Owusu" sort="Gyapong, John Owusu" uniqKey="Gyapong J" first="John Owusu" last="Gyapong">John Owusu Gyapong</name><name sortKey="Mills, Anne" sort="Mills, Anne" uniqKey="Mills A" first="Anne" last="Mills">Anne Mills</name><name sortKey="Whitty, Christopher J M" sort="Whitty, Christopher J M" uniqKey="Whitty C" first="Christopher J. M" last="Whitty">Christopher J. M. Whitty</name></country><country name="Ghana"><noRegion><name sortKey="Ansah, Evelyn Korkor" sort="Ansah, Evelyn Korkor" uniqKey="Ansah E" first="Evelyn Korkor" last="Ansah">Evelyn Korkor Ansah</name></noRegion><name sortKey="Asiamah, Sabina" sort="Asiamah, Sabina" uniqKey="Asiamah S" first="Sabina" last="Asiamah">Sabina Asiamah</name><name sortKey="Biantey, Kingsley" sort="Biantey, Kingsley" uniqKey="Biantey K" first="Kingsley" last="Biantey">Kingsley Biantey</name><name sortKey="Dickson, Kakra" sort="Dickson, Kakra" uniqKey="Dickson K" first="Kakra" last="Dickson">Kakra Dickson</name><name sortKey="Dzordzordzi, Vivian" sort="Dzordzordzi, Vivian" uniqKey="Dzordzordzi V" first="Vivian" last="Dzordzordzi">Vivian Dzordzordzi</name><name sortKey="Koram, Kwadwo Ansah" sort="Koram, Kwadwo Ansah" uniqKey="Koram K" first="Kwadwo Ansah" last="Koram">Kwadwo Ansah Koram</name><name sortKey="Narh Bana, Solomon" sort="Narh Bana, Solomon" uniqKey="Narh Bana S" first="Solomon" last="Narh-Bana">Solomon Narh-Bana</name></country></tree></affiliations></record>Pour manipuler ce document sous Unix (Dilib)
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