Are user fees a barrier to health care in poor countries?

The 1987 Bamako declaration promoted user or consultation fees for health care as a means to raise revenue and improve the quality of services. However, user fees may pose a barrier to access, and hence the key Sustainable Development Goal of Universal Health Coverage (UHC), for the global poor who typically have a high elasticity of demand for health services. The evidence has been mixed though on the impact of adding or removing user fees. A Cochrane review found that utilisation of services typically declined significantly with the introduction of fees and that quality was often found to improve with fees, but they also questioned the reliability of these studies due to a “high risk of bias”. Indeed, the evidence can be conflicting as to the effect of user fees on health service utilisation. Consider the following two studies from two similar countries: Malawi and Zambia.

The first looks at the effect the introduction and removal user fees had on health centre outpatient attendances, new diagnoses of malaria, and HIV diagnoses in a rural district of Malawi (which I should declare I authored!) Of 13 centres in Neno district, four were operated by the Christian Health Association of Malawi, of which one has always charged user fees and three introduced them in July 2013. The other centres were operated by the Ministry for Health and an NGO, Partners In Health, and did not charge fees. In July 2015, one centre removed user fees. These changes in charging status created a neat natural experiment. A plot of outpatient attendances shows what happened:

Figure 3

Even without modelling it is clear what happened – attendances dropped with the introduction of user fees and increased when they were removed. Similar changes were seen in new malaria and HIV diagnoses Further analysis also suggested patients weren’t moving between centres to avoid fees.

The second study, published this week, looks at a 2006 policy to remove user fees for publicly-funded health care facilities in rural districts across Zambia. The policy was instigated by the Zambian president as a step towards UHC, but was implemented haphazardly with funding not being completely in place and districts choosing to distribute the funding they received in different ways. Using data from a repeated cross-sectional health survey, the corresponding plot of the effects of the policy is:

userfees

Evident from this and reinforced by their synthetic control analysis, the policy did little to change the proportion of people seeking health care. The key impact of the policy was to reduce out of pocket expenditure as it seems people switched from using private providers to public providers. So why do the results of these studies, with seemingly similar ‘treatments’ in similar poor rural populations, differ so much?

In an earlier study of the Zambian policy it was found that outpatient attendances recorded in routine data – the same data used in the Malawi study above – there were large increases in use of public facilities when user fees were removed. The new study adds evidence though that this increase was a result of people switching from private to public providers. In Neno district, Malawi there are no private providers – only those in the study. Nevertheless, private providers also charge, so health care use in the face of fees was markedly higher in Zambia than Neno, Malawi. Perhaps there are relevant differences then in the populations under study.

Zambia, even in 2006, was much wealthier than Malawi in 2013. GDP per capita in comparable dollars was $1,030 in 2006 Zambia and $333 in 2013 Malawi. And Neno district is among the poorest in Malawi. The Malawi study population may be significantly poorer then than that in Zambia, and so have yet more elastic demand. Then again, Zambia is one of the most unequal countries in the world, its wealth generated from a boom in the copper price and other commodities. Its Gini coefficient is 57.5 as compared to Malawi’s 43.9. Thus, one may expect rural Zambians to perhaps be comparable to those in Malawi despite GDP differences. Unfortunately, there aren’t further statistics in the paper to compare the samples – and indeed no information on the relative prices of the user fees. And further, the Zambia paper does look at the poorest 50% of people separately and finds little difference in the treatment effect although there does appear to be large levels of heterogeneity in the estimated treatment effects between districts.

Differences in conclusions may also results from differences in data. For example, the Zambia study looked at changes in the reported use of formal health care among people who had an illness recently, whereas the Malawian study looked at outpatient attendances and diagnoses. Perhaps a difference could arise here such as reporting biases in the survey data.

It is not clear why results in the Zambian study differ from those in the Malawian one and indeed many others. It certainly shows the difficulty we have understanding the effect even small charges can have on access to care even as the quality of the evidence improves.

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ICU triage: a challenge and an opportunity

In a well-publicized snapshot of the challenge of ICU triage, Chang and colleagues wrote:

Critical care services can be life-saving, but many patients admitted to intensive care units (ICUs) are too sick or, conversely, not sick enough to benefit. Intensive care unit overutilization can produce more costly and invasive care without improving outcomes.

Emphasis added. Hyder provides an interesting critique to which Chang and Shapiro respond. In this post, I shall consider over-utilization by those “not sick enough to benefit”: 23.4% of the 808 patients admitted to the UCLA Medical Center in the study by Chang et al. This over-utilization provides both a challenge and a win-win opportunity (better outcomes at lower cost) if we can meet the challenge.

In a forward-looking vision, which some may regard as optimistic, Anesi et al wrote:

In the year 2050 we will unambiguously reimburse healthcare based on value, and so there is good reason to suspect that we will have targeted and reduced many services that provide little or no benefit to patients…

It can be argued that ICU over-utilization, on average, provides no overall benefit, while significantly increasing costs. Gooch and Kahn observed that US spending on critical care represents nearly 3% of GDP, while:

In contrast, the United Kingdom spends only 0.1% of its gross domestic product on critical care services, with no evidence of worse patient outcomes and similar life expectancies as in the United States. Although there are many differences between these 2 countries, one significant difference is intensive care unit (ICU) bed supply. The United States has 25 ICU beds per 100 000 people, as compared with 5 per 100 000 in the United Kingdom. As a result, ICU case-mix differs substantially. In the United Kingdom, the majority of ICU patients are at high risk for death, whereas in the United States, many patients are admitted to the ICU for observation.

As observed by Halpern, these differences come at a significant cost in the US:

The number of intensive care unit (ICU) beds in the United States has continued to increase over the last 3 decades, as have ICU utilization rates and costs, and this despite the lack of any federal, regional, or critical care society mandates to justify these increases. Some experts believe that the increase in the number of ICU beds has led to inappropriate use of these beds by patients who are either too healthy or too sick to benefit from intensive care. This may in part explain the stable national ICU occupancy rate of approximately 68% between 1985 and 2010 and suggests that ICU utilization has simply risen to meet the increased number of beds.

Emphasis added. I shall consider here only ICU usage by patients too healthy to benefit. Although the economics behind reducing ICU over-utilization by “those not sick enough to benefit” appears simple, the underlying cause is in fact likely complex.

icu-costs-fig-1

This one appears easy: lower costs and potentially better outcomes

At the same time, I recall several caveats, well known to health economists, but important in planning and communication:

  1. We expect ICUs to be available when needed, including for emergencies and disasters,
  2. ICUs have high fixed costs,
  3. Decision-making is critical: incremental costs of adding capacity become fixed costs in the future.

Chris Sampson recently reviewed a study aimed at overconsumption or misconsumption (a consequence of over-utilization). The authors of that paper suggest that “cultural change might be required to achieve significant shifts in clinical behaviour.” Chris laments that this study did not ‘dig deeper’; here we aim to dig deeper in one specific area: ICU triage for patients “not sick enough to benefit.” More questions than answers at this stage, but hopefully the questions will ultimately lead to answers.

I begin by stepping back: economic decisions frequently involve compromises in allocating scarce resources. Decisions in health economics are frequently no different. How scarce are ICU resources? What happens if they are less scarce? What are the costs? Increasing availability can frequently lead to increased utilization, a phenomenon called “demand elasticity”. For example, increasing expressway/motorway capacity “can lead to increased traffic as new drivers seize the opportunity to travel on the larger road”, and thus no reduction in travel time. Gooch and Kahn further note that:

The presence of demand elasticity in decisions regarding ICU care has major implications for health care delivery and financing. Primarily, this indicates it is possible to reduce the costs of US hospital care by constraining ICU bed supply, perhaps through certificate of need laws or other legislation.

I offer a highly simplified sketch of how ICU over-utilization by those “not sick enough to benefit” is one driver of a vicious cycle in ICU cost growth.

icu-costs-fig-2

ICU over-utilization by patients “not sick enough to benefit” as a driver for ICU demand elasticity

Who (if anyone) is at fault for this ICU vicious cycle? Chang and Shapiro offer one suggestion:

For medical conditions where ICU care is frequently provided, but may not always be necessary, institutions that utilize ICUs more frequently are more likely to perform invasive procedures and have higher costs but have no improvement in hospital mortality. Hospitals had similar ICU utilization patterns across the 4 medical conditions, suggesting that systematic institutional factors may influence decisions to potentially overutilize ICU care.

Emphasis added. I note that demand elasticity is not in itself bad; it must simply be recognized, controlled and used appropriately. As part of a discussion in print on the role of cost considerations in medical decisions, Du and Kahn write:

Although we argue that costs should not be factored into medical decision-making in the ICU, this does not mean that we should not strive toward healthcare cost reduction in other ways. One strategy is to devise systems of care that prevent unnecessary or unwanted ICU admissions—given the small amount of ICU care that is due to discretionary spending, the only real way to reduce ICU costs is to prevent ICU admissions in the first place.

Du and Kahn also argue for careful cost-effectiveness analyses, such as that supported by NICE in the UK:

These programs limit use of treatments that are not cost-effective, taking cost decisions out of the hands of physicians and putting them where they belong: in the hands of society at large… We will achieve real ICU savings only by encouraging a society committed to system-based reforms.

Emphasis added. One can debate “taking cost decisions out of the hands of physicians”, though Guidet & Beale‘s and Capuzzo & Rhodes‘s argument for more physician awareness of cost might provide a good intermediate position in this debate.

Finally, increasing ICU supply (that is, ICU beds) in response to well-conceived increases in ICU demand is not in itself bad; ICU supply must be able to respond to demands imposed by disasters or other emergencies. We need to seek out novel ways to provide this capacity without incurring potentially unnecessary fixed costs, perhaps from region-wide stockpiling of supplies and equipment, and region-wide pools of on-call physicians and other ICU personnel. In summary, current health-related literature offers a wide-ranging discussion of the growing costs of intensive care; in my opinion: more questions than answers at this stage, but hopefully the questions will ultimately lead to answers.

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