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.
« Obama goes the extra bipartisan mile | Main | It's the thought that counts » Patient, heal thyself06 Jan 2009 01:44 pm
I don't find it surprising when studies of American/European health care consumption show little relationship between consumption and health outcomes. After a certain point, after all, iatrogenic morbidity and mortality has to outweigh the benefit of marginal treatment. But I confess I am shocked that studies show the same thing in the developing world:
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I am not bright, can you explain what this means in simpler words?
Explanation: Giving away free health care doesn't seem to make people any healthier.
See GMU economist Robin Hanson for more on the same topic.
Most of your health outcome is determined long before you step into the hospital. Habits, usage of OTC drugs, proximity to crime and motor vehicles, and a surprisingly small number of relatively cheap prescription drugs will determine most of your likely health outcome.
Most of this can be trivially observed by walking around in a hospital for five minutes and observing the incredibly high number of obese, drug-addicted, alcoholic, nicotine-addicted, or motorcycle-riding people there. The effect of a marginal dollar of medical expenditure on such patients, or for that matter a marginal million dollars, tends to be rather low.
I, as a motorcycle rider, am willing to admit this.
This is an interesting study, though it's hard to make too much of it from the abstract alone.
I have a couple of thoughts. First, the population being studied (children under 5) tend to be relatively healthy as a baseline. Barring catastrophic illness or injury, most do very well with minimal intervention. Measuring the outcomes of a population that might benefit from more aggressive health intervention (ie. older patients) could have yielded different outcomes.
On a similar note (and I'm not an expert regarding medicine in the developing world), most of the factors that are likely to make the biggest difference in a place like Ghana are going to be things such as clean water and access to nutrition. Assuming that differences between the groups were controlled for, basic health care interventions aren't likely to make a big difference one way or another.
As a pediatrician, it's a bit humbling to have to admit that most of what we do is screen to make sure there are no Big Horrible Illnesses lurking in the background.
Hard to tell from the abstract, but it seems they were linking treatments for malaria (which they noted could be significantly improved with early intervention) with measured anemia suffered. A couple of thoughts: 1) Aren't there a lot of other causes for malaria, such as parasites, which may or may not have been as susceptible to early intervention; and 2) I'd be interested to see how they measured compliance with prescribed treatments.
Still, very interesting result.
The article points ahead to this commentary, which I, being confused, found pretty helpful.
Ah! Thanks for clarifying, CJS. It takes a really close reading of the abstract to get that. It makes the results a bit more interesting.
CJS, there is only one ultimate cause (though four species) of malaria. It is a parasite, though one spread by mosquito.
Thanks Devilbunny - my typo. I typed "malaria" when I meant "anemia" in point 1. I don't know if that makes it any more coherent, given I'm a lawyer in my day job. When I re-read, I did note that the authors recorded they had similar instances of parasites, but I don't know if that meant the malaria-causing parasites or other parasites.
This study should come as no surprise to any of the pediatricians old enough to remember going on house calls. After free vaccinations were introduced in the '50's, the number of vaccinations did not rise. The only thing that increased the number of vaccinations was states beginning to require certain mandatory vaccinations before permitting kids to enroll in elementary school.
One can also look at the current health insurance debate, where the proponents of universal health insurance are very careful to frame the debate in terms of insurance and not access. Universal access is already here; no matter how much or how little you make, or how much or how little coverage you have, you cannot be turned away from any emergency room in the country. So the debate is couched in terms of insurance, not access.
After free vaccinations were introduced in the '50's, the number of vaccinations did not rise.
But the thing is, in this study the utilization of the subsidized healthcare *did* rise by a significant amount in the studied group. It just didn't seem to help their outcomes. So this result can't be chalked up just to them not making use of the provided healthcare.
Quite apart from any confounding variables, this makes no sense, statistically speaking. That is, you can't conclude anything from this study, given the confidence intervals, sample size, yadda yadda. If I can trust to a quick BOTEC, there is actually a good chance that there was significant positive effect, even given the conditions.
As medical studies go, though, this is actually rather large and well randomised, especially since the disease they are testing for has high expected and actuall prevalence.