1. The effects of reducing the direct cost of care on health services utilization and health outcomes in Ghana: a randomized controlled trial EVELYN KORKOR ANSAH ICIUM 2011, TURKEY

2. Background Direct cost of health care is a major barrier to care and potentially one of the most modifiable Mechanisms aimed at reducing the direct cost of care have been instituted in many countries. However, direct evidence that reducing financial barriers has a positive impact on health outcomes is limited. Observational studies, which tend to be carried out may be subject to many potential biases. This trial aimed to assess the impact of reducing barrier due to direct cost of care on malaria- associated health outcomes ICIUM 2011, TURKEY

3. Study Questions Will increased household financial access to health care lead to increased health service utilization ? Will this result in improved health outcomes ? ICIUM 2011, TURKEY

4. Study Setting Dangme West District in Ghana Rural, with scattered settlements and wide spread poverty A district wide pre- payment scheme was in its 5 th year of operation People enrolled entitled to all primary care free, incl. drugs. Also, free hospital care up to a ceiling ICIUM 2011, TURKEY

5. Study Design A two-arm randomized controlled unblinded trial. The HH was the unit of randomization All HH not yet enrolled in the scheme at time of closure of enrolment window with chn 6-59 mths eligible. Simple random sample A baseline HH survey of 2,151 HH with 2,524 chn 6-59 mths carried out post randomization Followed by a 6-mth period of passive morbidity monitoring Final HH cross-sectional survey was carried out at end of 6-mth period ICIUM 2011, TURKEY

6. Intervention Members of HHs in intervention arm were enrolled into the existing pre-payment scheme which provided the following benefits:  Individual photo-IDs which allowed free unlimited access to primary care at any of the 10 clinics PLUS secondary care up to a US$45 ceiling in any of 5 hospitals of their choice Members of HH in the control grp paid for their health care out of pocket with promise of equivalent benefit the ff yr HHs could not change their grp till study end ICIUM 2011, TURKEY

7. Screening, enrollment and randomization Allocation to the two arms was by simple randomization (community ballot) stratified by distance { 10km} This was to ensure community acceptance ICIUM 2011, TURKEY

8. Follow-up - Passive Morbidity monitoring by pictorial diary method with avg. 7.5% LFUP ICIUM 2011, TURKEY

9. Final Cross-sectional survey ICIUM 2011, TURKEY

10. Comparability of groups at baseline- demographics, outcomes, malaria prevention, wealth quintiles ICIUM 2011, TURKEY

11. Results- Utilization of healthcare Visits/pers on- year Control n=1197 Interventi on n=1124 p-value95% CI Primary Care Clinic 2.502.800.0011.04-1.20 Chemical seller 2.972.69<0.0030.85-0.97 Home Treatment 2.011.790.0050.82-0.96 Non-formal care 5.104.59<0.0010.86-0.95 ICIUM 2011, TURKEY

12. Results: Utilization of Informal sector care Among the intervention group, use of informal care was significantly lower among those living close to the health facility But, as distance from HF increased, informal sector use increased among both control and intervention groups Gates Malaria Partnership

13. Results- Health outcomes Control n=1197 Intervention n=1124 p-value Hb<8g/dl (%)37 (3.1)36 (3.2)0.88 Hb<6g/dl (%)3 (0.25)2 (0.2)0.71 Mean Hb11.011.10.47 Mean change Hb +0.71+0.750.69 Deaths450.67 ICIUM 2011, TURKEY

14. Primary outcome: effect on moderate anaemia (Hb<8g/dl) OR (95% CI)p-value Crude1.04 (0.65-1.65)0.877 Adjusted for age, sex, distance, poverty, clustering 1.05 (0.66–1.67)0.837 ICIUM 2011, TURKEY

15. Lessons learnt Those who enrol voluntarily in pre-payment schemes are significantly different from those who do not. Non-randomized study designs may suffer from bias as a result of this Improved financial access led to significant change in healthcare use but not in measured health outcomes Non-financial barriers (such as distance) are important influences in care-seeking in this setting

16. Policy Implications & Research Gap Policy implication There is a need to find innovative ways to remove non-financial barriers to health care in order to ensure real access to those who really need it Research Gap Need to consider randomized designs in evaluating the effect of health financing interventions in other settings ICIUM 2011, TURKEY

17. Acknowledgements Funding by Gates Malaria Partnership, LSHTM LSHTM, UK Prof. Richard Hayes Prof Brian Greenwood Prof Anne Mills Prof. Christopher Whitty Noguchi Memorial Institute for Medical Research, Ghana  Mr. Kakra Dickson  Prof. Kwadwo Koram Ghana Health Service Mr. Solomon Narh-Bana Mr. Kingsley Biantey Mrs. Sabina Asiamah Ms. Vivian Dzordzordzi Prof. John Gyapong Dr. Margaret Gyapong Prof Irene Agyepong Acad. Med. Centre Netherlands  Dr. Teunnis Eggelte ICIUM 2011, TURKEY