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

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.

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.

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.