Increasing the uptake of health services in low-income countries: What can we expect from user fee removal and financial incentives?

Lead Research Organisation: London Sch of Hygiene and Trop Medicine
Department Name: Public Health and Policy

Abstract

Increasing the uptake of health services by the poorest and most vulnerable populations is required to improve health outcomes and more ultimately to alleviate poverty. Over the last decades, there have been many changes regarding the perception of the main predictors of health services uptake in low-income countries. User fees were introduced in most of African countries in the late 80's based on the idea that even the poorest individuals had some ability to pay for health, especially if the quality of care is high. More recently low-income countries have implemented several policies such as user fee removal, universal health insurance and financial incentives in order to improve health care use of the poorest populations. Although those new health policies have provided researchers with an unique opportunity to explore the role of income on health services uptake, the use of inappropriate methods to analyse impacts or the poor design and external validity of RCTs conducted in this area has failed to provide some evidence on the impact and transmission channels through which those policies indirectly affecting income affects health service uptake.

I propose to undertake a comprehensive and original programme of research to address this gap in knowledge. Using advanced econometric techniques the research will first investigate the impact of income and health facilities' characteristics on health care use in four low-income countries. Then, I will investigate the effect of user fee removal in Zambia on access, out-of-pocket medical expenses and on economic vulnerability. Finally, I will investigate the effect of income for patients with different levels of risk aversion on adherence to PrEP among HIV sero-discordant couples in Nigeria. To do so, I plan to develop a small research project part of the PrEP demonstration project that will be implemented in Nigeria and will aim to investigate the determinants of adherence to PrEP in Nigeria. The findings regarding the determinants of PrEP adherence will be used to design a RCT that will highlight the optimal amount and the best manner to allocate the financial incentive (cash payment versus lottery) to maximise its effects on adherence to PrEP.

The MRC early career fellowship in economics of health will thus provide for the publication of a series of papers on the role of income in the uptake of curative and preventive health services in low-income countries. The results of this research will be disseminated to an academic audience and to policy-makers through presentations, seminars and conferences. The production of this proposal will be supported by a series of training modules in impact evaluation econometric techniques and impact evaluation design.

Technical Summary

Motivation: Additional evidence on the direct role of income on health services utilisation and on the health policies that indirectly increase income to stimulate the uptake of health services in LMICs is needed to increase the allocative efficiency of health expenditure.

Aim: To provide additional evidence on the direct and indirect role of income on the use of health services in LMICs

Method:

(1) The effect of income on health care use controlling for the characteristics of health facilities will be estimated by using instrumental variables approach to correct for the endogeneity of income and the availability and quality of care. The analysis will be conducted in 4 LMICs (Ethiopia, India, Peru and Vietnam). I will compare the findings and investigate why income is a stronger predictor of health care use in some contexts.
(2) A double difference estimator will be used to quantify the impact of user fee removal in Zambia on health care use, out-of-pocket medical expenses and catastrophic expenditure. The econometric analysis will report the intention to treat the local average treatment effect.
(3) In Nigeria, HIV negative partners in sero-discordant relationship will be randomly selected in ART clinics to participate in a study that will consist in analysing the effect of income, risk aversion and their interaction on adherence to PrEP. Information on income and on direct and indirect costs of PrEP will be collected and risk aversion level will be assessed through a experimental economic game.
(4) The results obtained from the research experiment in Nigeria will be used to design a RCT that will highlight the best manner to allocate a financial incentive (lottery versus cash payment) and the amount of the financial incentive that is likely to be the most cost-effective.

Outputs: I expect to publish those findings in top health economics or development economics journals. Findings will be widely disseminated to academics and policy makers.

Planned Impact

The research is anticipated to benefit to a large audience beyond the academic community, including international organisations and decision-makers and through these, the wider public.

By providing additional insight on the role of income in the uptake of health services in low-income countries, the research will inform policy-makers and international organisations of the effective health policies that could be implemented to increase the uptake of health services of the most vulnerable populations.

As highlighted in my case for support, Governments often decide to implement health policies that have a large impact on their fiscal space with limited evidence on their efficacy. Knowing what could be the most effective health policies as well as the best design to improve the health status of the populations in low-income countries will allow to improve the allocative and technical efficiency of health expenditures, which will allow creating fiscal space in the targeted countries.

For the same reasons, the research is expected to have an impact on international donors (bilateral and international organisations) since it will provide evidence on the health interventions to support. In this sense, the results of the research project will enhance greater allocative efficiency of aid, which will save UK resources.

Finally, the research on PrEP could be of interest for UK researchers working on HIV/AIDS. In 2012, the Food and Drug Administration (FDA) in the US approved Truvada for use as PrEP and it is expected that a similar regulatory approval will be sought from the European Medicines Agency (EMA) in the near future. It is then important to know what could be an effective policy to support the adherence to PrEP in order to reach maximal effect.

Publications

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Description Aix Marseille school of economics small grant
Amount € 10,000 (EUR)
Organisation Aix-Marseille University 
Sector Academic/University
Country France
Start 04/2015 
End 07/2015
 
Description Bloomsbury college PhD studentship
Amount £45,000 (GBP)
Organisation Bloomsbury Colleges 
Sector Academic/University
Country United Kingdom
Start 08/2018 
End 09/2021
 
Title Small data set on serodiscordant couples in Nigeria 
Description This data set includes information on sexual behaviours, risk aversion and subjective expectations of 50 sero-discordant couples (n=100). This data set resulted from the formative research of the pre-exposure prophylaxis (PrEP) demonstration project among sero-discordant couples in Nigeria. 
Type Of Material Database/Collection of data 
Year Produced 2015 
Provided To Others? No  
Impact The data set was collected and used by two MSc students during their summer project. 
 
Description Collaboration with Aix-Marseille school of Economics 
Organisation Aix-Marseille University
Department School of Economics
Country France 
Sector Academic/University 
PI Contribution This collaboration started when I received an invitation from Dr Bruno Ventelou, senior lecturer in health economics at Aix Marseille School of Economics (AMSE), to present a paper in a seminar. During this short stay in Marseille, I met Dr. Carole Treibich, a postdoctoral researcher who did her PhD on risk aversion. Together we decided to apply for a small grant to collect data on risk aversion of sex workers in Dakar. I have lead this data collection work and initiated a collaboration with the Ministry of Health of Senegal to make this data collection possible. I will be a visiting researcher from April to July 2016 at AMSE to work on a research agenda in order to analyse sexual behaviours of sex workers with Dr. Carole Treibich
Collaborator Contribution Dr. Carole Treibich spent several months in Dakar to supervise data collection on the field and is a co-author of the research outcomes that use these data.
Impact So far we have written the following working papers. Both have been submitted to peer reviewed economics journals: 1. Does Risk Aversion Predict Sexual Behaviours and the Demand for HIV/STI Prevention? Evidence from Sex Workers in Dakar Abstract: We measured risk aversion among sex workers in Dakar using economic experimental games with real payment as well as self-reported risk aversion based on visual scales. Self-reported risk aversion was collected in reference to several domains: in general, with money, with health and with sexual behaviours. We find that sex workers reporting a greater risk aversion in health and sex have a greater demand for STI/HIV prevention and adopt less risky sexual behaviours. However, risk aversion in money does not correlate with risky sexual behaviours. 2. Measuring unbiased condom use and its determinants among high-risk groups: Evidence from a list experiment among female sex workers in Dakar Abstract: Condom use is the main preventive tool available to limit the spread of sexually transmitted diseases (STI) and human immunodeficiency virus (HIV). Given that the consistent use of condoms is known as the most cost-effective way to prevent HIV transmission, condom use is the pillar of any HIV prevention strategy in most countries. The promotion of condom use is often based on multiple interventions such as awareness campaigns and the free provision of condoms. However, the evaluation of the effects of such policies is difficult due to the impossibility to directly observe sexual behaviours adopted by targeted groups. Researchers and policymakers have then no other choice than relying on individuals' declarations. Yet, one may wonder whether direct elicitation of condom use will provide an accurate estimate. In order to test the assumption that self-reported condom use is highly biased among high-risk populations, we use a list experiment, an indirect elicitation method that is expected to yield more truthful responses. The result from the list experiment indicates that 20.40% of female sex workers did not use a condom in their last sexual intercourse with a client, which is a significant increase when compared to the 2.75% obtained when asked directly. When estimating condom use among sub-groups, we find that HIV positive FSWs (estimated via biological markers) have a lower condom use (5% for HIV positive FSW against 80% for HIV negative FSWs). We also find that FSWs who believe that they have another STI than HIV (estimated via subjective expectations) are significantly less likely to have used a condom with their last client (65% for FSWs declaring having at least a 10% probability of having a STI versus 90% for FSWs with a subjective probability inferior or equal to 10%). Those results have important epidemiological implications in a country where HIV transmission is mainly driven by female sex workers.
Start Year 2015
 
Description Collaboration with the Institute of Developing Economies in Japan 
Organisation Institute of Developing Economies in Japan
Country Japan 
Sector Academic/University 
PI Contribution I empirically tested the model developed by my collaborator.
Collaborator Contribution My collaborator, Dr. Seiro Ito, developed a theoretical model that predicts the effect of the registration policy for sex workers on health. We co-organised a dissemination workshop of those results in 2016.
Impact http://www.ide.go.jp/English/Publish/Download/Dp/676.html
Start Year 2014
 
Description Collaboration with the Ministry of health of Senegal 
Organisation Government of the Portugese Republic
Department Ministry of Health Portugal
Country Portugal 
Sector Public 
PI Contribution This collaboration led to the creation of a longitudinal data set from sex workers in Senegal and joint research papers.
Collaborator Contribution My national collaborator provided guidance and support to obtain national ethical clearance. They gave us authorisation to conduct our survey in four public hospitals and provided biological tests.
Impact We are currently working on several papers that use this data set. This collaboration is multi-disciplinary and involves the following disciplines: economics, public health, policy.
Start Year 2015
 
Description Collaboration with the National Agency for the Control of AIDS in Nigeria 
Organisation National Agency for the control of AIDS (NACA) in Nigeria
Country Nigeria 
Sector Public 
PI Contribution Together with employees of NACA, I developed economic sections of the questionnaire that will be used for the of pre-exposure prophylaxis (PrEP) demonstration project among sero-discordant couples. I have organised the formative phase to pilot these sections in summer 2015 when I supervised two MSc students of the LSHTM who piloted the questionnaire on 100 individuals in a sero-discordant relationship in Nigeria.
Collaborator Contribution My national collaborators provided support to the students on the field. They helped them to get ethical clearance, they made this data collection possible by providing authorisation and help to recruit sero-discordant couples.
Impact The main outcome that resulted from this partnership is the piloted questionnaire that is currently used on the field to measure risk aversion and subjective expectations of sero-discordant couples part of the PrEP demonstration project. This collaboration is multi-disciplinary and involves the following disciplines: economics, public health, policy.
Start Year 2012
 
Description CSAE 2015 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact I presented a working paper on the effect of user fee removal in Zambia. This paper was discussed by a researcher from the University of Stellenbosch and by the audience. Thanks to this conference, this paper was cited in the blog on development economics of the World Bank: http://blogs.worldbank.org/impactevaluations/csae-2015-impact-evaluation-round

At this conference, I also discussed a paper from a researcher of Harvard University.
Year(s) Of Engagement Activity 2015
URL https://editorialexpress.com/conference/CSAE2015/program/CSAE2015.html
 
Description CSAE 2017 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact I have presented the result of my research looking at the effect of the registration policy for sex workers in Senegal on physical and mental health.
Year(s) Of Engagement Activity 2017
 
Description Fondation Méditerranée Infection/SESSTIM 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact I was invited by the school of medicine in Marseille to give a talk on how to measure misreporting of sensitive health behaviours.
Year(s) Of Engagement Activity 2016
 
Description The third EuHEA PhD student-supervisor and early career researcher conference, 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact I presented a paper that was discussed at this event.
Year(s) Of Engagement Activity 2016
 
Description Twenty Fourth European Workshop on Econometrics and Health Economics 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact My working paper on the effect of user fee removal in Zambia was selected at this workshop. My co-author Mylene Lagarde presented the paper and the paper was discussed by Dr. Fabrizio Mazzonna. This event was attended by renowned health economists and applied econometricians internationally and we received very positive feedback regarding our paper. The editor of the journal Health Economics was enthusiastic regarding our paper and encouraged us to submit the paper to this journal.
Year(s) Of Engagement Activity 2015
URL https://www.york.ac.uk/media/economics/documents/herc/ew/EW24%20Programme.pdf
 
Description Workshop on sex work in Senegal 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact I organised a workshop to disseminate the findings from our research conducted on sex workers in Senegal to policymakers and the civil society. The two-day event took place at the STI/HIV division of the ministry of health in Dakar and was attended by about 60 participants each day.
Year(s) Of Engagement Activity 2016
 
Description iHEA 2015 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact I presented a paper at this conference.
Year(s) Of Engagement Activity 2015
URL https://ihea2015.abstractsubmit.org/sessions/2598/
 
Description iHEA 2017 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact I will present a paper from my fellowship at iHEA 2017, the leading conference in health economics.
Year(s) Of Engagement Activity 2017