title: Effect of removing direct payment for health care on utilisation and health outcomes in Ghanaian children: a randomised controlled trial.
abstract: BACKGROUND
  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.
  
  
  RESULTS
  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.
  
  
  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.
authors.affiliation: London School of Hygiene & Tropical Medicine, London, United Kingdom. ansahekdr@yahoo.co.uk
authors.forename: Evelyn Korkor
authors.initials: EK
authors.lastname: Ansah
authors.forename: Solomon
authors.initials: S
authors.lastname: Narh-Bana
authors.forename: Sabina
authors.initials: S
authors.lastname: Asiamah
authors.forename: Vivian
authors.initials: V
authors.lastname: Dzordzordzi
authors.forename: Kingsley
authors.initials: K
authors.lastname: Biantey
authors.forename: Kakra
authors.initials: K
authors.lastname: Dickson
authors.forename: John Owusu
authors.initials: JO
authors.lastname: Gyapong
authors.forename: Kwadwo Ansah
authors.initials: KA
authors.lastname: Koram
authors.forename: Brian M
authors.initials: BM
authors.lastname: Greenwood
authors.forename: Anne
authors.initials: A
authors.lastname: Mills
authors.forename: Christopher J M
authors.initials: CJ
authors.lastname: Whitty
mesh_terms: D000740:Anemia / Q000188:drug therapy / Q000453:epidemiology / Q000209:etiology; D002675:Child, Preschool; D005249:Fees and Charges; D005869:Ghana / Q000453:epidemiology; D017048:Health Care Costs; D006296:Health Services / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000191:economics*; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D008288:Malaria / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D017063:Outcome Assessment, Health Care; D018512:Parasitemia / Q000453:epidemiology; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D017061:Prepaid Health Plans / Q000191:economics / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires
chemical_list: D006454:Hemoglobins