Removing Barriers To Health Care

– Does What For Health?

Perform this experiment in your head, if you will…

Make health care easier to get in this country.  What would you expect to happen to the health of the communities where it’s done?  Many would say that the general health of the population in question would get better.  Then, on reflection, many would say, “Well, it would get better, but only somewhat, or a little.  Compared to most of the world, the health of most in this country is pretty good to begin with.”

And if you substitute, say, Europe for “this country” in our little thought experiment, you’d probably get the same response.  Right?  But if you made health care easier to get in poorer countries, most everyone would say that they expect the health of the communities where it’s easier to get to become better.  Replace “easier to get” with “cheaper” or even “free” and I’d expect the effects to be even more pronounced.  Measurable, even.

So let’s do the experiment, shall we?

We don’t have to.   It’s been done.

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.

The authors of the study I’m quoting are performing just such an experiment.   They next go through some explanation of their methods and rationales for some of the decisions they made for counting.  It’s not long, and worth reading, but let’s jump to the conclusions.

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.

(All emphasis mine.) Oops.  The health of the community didn’t improve?  Who ordered up this result???  That may be a good question.  In a case like this, it’s always important to see who funded the study.

The study was sponsored by the Gates Malaria Partnership with funds from the Bill & Melinda Gates Foundation (BMGF). The BMGF did not have any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Seems non-biased enough.  This article appears in the Public Library of Science (PLoS) journal.  It’s not one of the more famous medical/science journals, but it is peer-reviewed and published.  Even the editors are obliged to agree and say (in a mealy mouth sort of way) that the results have to be taken in the context in which they were made.  In essence, they say “We don’t like these results either, but here they are.”  At least, that’s my reading of this:

These findings show that, in this setting, the removal of out-of-pocket payments for health care changed health care-seeking behavior but not health outcomes in children. This lack of a measured effect does not necessarily mean that the provision of free health care has no effect on children’s health—it could be that the increase in health care utilization in the intervention arm compared to the control arm was too modest to produce a clear effect on health. Alternatively, in Ghana, the indirect costs of seeking health care may be more important than the direct cost of paying for treatment.

That’s a shrug if I ever saw one written.

Although the findings of this trial may not be generalizable to other countries, they nevertheless raise the possibility that providing free health care might not be the most cost-effective way of improving health in all developing countries. Importantly, they also suggest that changes in health care utilization should not be used in future trials as a proxy measure of improvements in health.

That’s not just one admission; It’s two.  “Free health care may not be cost effective.” and “More health care may not be better health care.”  The world never seems to work the way we expect it to.  Does it?

Big hat tip to Megal McArdle at Asymmetrical Information.

Explore posts in the same categories: Health, Science

2 Comments on “Removing Barriers To Health Care”

  1. Becky Says:

    Not having read the study, I wonder if increased health care also turned up more problems, thereby lowering the incidence of better health…did that make sense?

    If everyone who thought they were healthy and had stayed away from doctors got a thorough checkup, the unhealthy quotient might go up as previously undetected concerns surfaced.

  2. joe Says:

    Good thought, Becky – but the study limited itself for that very reason to one malady, malaria. That’s the only thing they counted in this case.

    But your second point is spot on. Better detection makes the numbers look worse. And it’s very hard to tease out the effect of “more” health care when you already know that this will make the numbers of disease cases go up.

    Still, they say they accounted for that effect. They look at the final mortality and morbidity rates and ultimately, they’re no better after treatment is given.

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