New Study: Free Health Care Didn't Improve Outcomes

A new study from a randomized experiment in Ghana showed that when primary health care was made free, people used health care more often but weren't any healthier:

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.

Methods and Findings

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 authors include the obvious caution that their results are not generalizable to other countries. Still, the results do suggest that researchers shouldn't automatically assume that giving people more health care leads ineluctably to greater health:

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.

On a broader note, Abhijit Banerjee and Esther Duflo have a very interesting paper here discussing a wide range of randomized trials as to all sorts of governmental policies.

UPDATE: This post seems to have caught some attention: Megan McArdle, The American Scene, Overcoming Bias, Marginal Revolution.