This project conducts a randomized controlled trial of two health care policies in a peri-urban region of Bamako, Mali: the provision of free primary care, and regular visits from health workers who teach mothers good practices and accompany children to the doctor.
The authors will use this experiment to learn about the effects of these policies on the use of healthcare resources by the mothers of young children - in particular when they seek medical care, who they seek care from, and the use of preventive measures such as mosquito nets and water purification.
The results will also be used to study the importance of different types of constraints that may govern the healthcare decisions of poor families, such as lack of available credit, or lack of knowledge of good healthcare practice.
The project will improve understanding of how the abolition of user fees can alleviate these constraints, and whether health workers can counteract some of the negative implications associated with providing healthcare entirely for free. Ethical approval for this project has been obtained from Brown University and the Comite National D’Ethique Pour La Sante et Les Sciences De La Vie in Mali
Our proposed research will have an impact in four distinct groups of beneficiaries.
First, as discussed in the 'Academic Beneficiaries' section, we expect our findings, data and methodology to make significant contributions in the fields of health, development and behavioral economics, as well as public health and demography.
Second, we anticipate that our research will benefit policy making bodies at a local, national and international level. Improving healthcare access for mothers and children are two of the most important aims of global development policy, and are included in the Millennium Development Goals. Child health is a particularly urgent concern in Mali, where the under-five mortality rate is the second-highest in the world. Our project is motivated by the active policy debate about how to fund healthcare in developing countries. The consensus in the 1980's, endorsed in the 1987 Bamako initiative, was that user fees were the best way to deliver high-quality service and prevent waste and over-utilization. Free care could encourage overuse and moral hazard (behaviors that inefficiently increase the cost of care, such as foregoing prevention). Opponents of user fees point out that they reduce health care access for the poor and negatively affect health and economic welfare. Furthermore, providing healthcare for free may improve efficiency if it helps offset other barriers to access, such as credit constraints. As a consequence, aid organizations now frequently advocate free care, and many African countries have returned to (partially) free healthcare. The debate about user fees centers on their impact on behavior, and the interaction between fees and household constraints. Our study will help to determine the effects of free medical care on important healthcare behaviors, such as when to seek care during a spell of illness or whether to use preventive care, and study the extent to which free care can offset barriers to access. Our findings will inform the debate by providing information on the efficiency gains and losses associated with free care. We can determine household circumstances in which the efficiency losses are small (or gains are large). The policy intervention that we study is innovative in its combination of free care with healthcare worker visits. The latter have the potential to offset some of the efficiency losses associated with free care, by providing households with information about the health of the child (and so the need for treatment), and 'nudging' families towards better healthcare behaviors (such as the use of preventive care). Our study will help determine whether healthcare workers can successfully perform this role. Finally, our project will culminate in the development of a dynamic structural model that can be used by policymakers to estimate the effects of related interventions on different populations prior to running further randomized controlled trials.
Third, our research will benefit third sector organizations involved in the delivery of healthcare in developing countries. Most immediately, Mali Health will use the results of our study to optimize their programs and adjust the elements of Action for Health for currently enrolled families as well as for future expansions. It is also the stated aim of our partner organization to disseminate best practice to other providers within West Africa and beyond.
Finally, the study will be of benefit to the general public by leading to more efficient healthcare delivery. Mali Health plans to offer a version of the Action for Health program to 2400 children and their families by the end of 2014, for an estimated number of 13300 direct beneficiaries. In the long term they plan to expand into other Bamako neighborhoods. Indirectly, if the policy lessons from our study are adopted by governmental and non-governmental providers, the number of beneficiaries can be far larger.