Determinants of Health Care Decisions: Children's Health in Mali

发展中国家初级保健，特别是儿童初级保健的提供和供资问题是持续辩论的主题-尤其是鉴于儿童发病率和死亡率仍然低于千年发展目标。有证据表明，免费保健的利用率有所提高，保健成果有所改善，因此许多非洲国家最近完全或部分取消了使用费。然而，可以说，免费医疗可能导致过度使用和道德风险，例如减少预防工作。在补贴医疗以减少因市场失灵而产生的获取障碍与保持价格在有效引导资源流向最重视资源的人方面的作用之间存在着紧张关系。本项目的目标是研究提供免费医疗和免费卫生工作者探视对父母为子女健康做出的三项重要决定的影响：他们在急病期间等待就医的时间、使用预防性护理以及使用正规与非正规部门护理的情况。卫生工作者出诊与免费保健相结合，有可能增加贫困家庭获得保健的机会，同时减少与取消用户费用相关的低效率-例如过度使用初级保健和未充分使用预防性保健：卫生工作者可以向父母提供有关保健需求的更好信息，并"推动“他们采取更好的保健做法。我们研究了这些政策与家庭的三个关键特征的相互作用，这可能会导致父母对孩子的照顾不足，如果他们面对市场价格：财政限制和无法借贷或储蓄;有关健康和医疗保健的信息不足;和父母的支出优先事项的可能性不同的决策者。政策影响决策的渠道是重要的，在理解效率的收益和损失，取消用户费和卫生工作者的潜力，以抵消这些losss.The数据为这个项目来自一个随机对照试验（RCT）进行的郊区巴马科，马里。随机对照试验包括两项干预措施：儿童免费初级保健和卫生工作者免费出诊。对于每一个孩子，我们收集了关于社会经济背景的独特详细数据以及10周内的完整健康史-每天详细介绍孩子表现出的所有症状以及母亲寻求的所有医疗保健。这些数据使我们能够详细研究免费医疗保健和卫生工作者访问如何影响父母的医疗保健行为，以及这些影响如何取决于家庭的财务资源，其对健康问题的知识和信念，以及其偏好。在这种情况下，卫生工作者的干预是特别有趣的，因为它可能一方面能够更直接地解决效率低下的问题，因此是免费医疗的一个可行的替代方案，另一方面，它可能提供一种手段，以抵消一些免费医疗的效率低下。正因为如此，它将帮助我们了解阻止不同类型的家庭获得高质量护理的限制因素。这反过来将使我们能够开发一个模型，我们可以用来估计我们直接测试的政策以外的政策的影响-例如部分取消费用或经济状况调查补贴。通过这种方式，我们的方法将为医疗保健政策的循证设计做出重大贡献

The delivery and funding of primary healthcare in developing countries, particularly for children, is the subject of sustained debate -- not least in light of child morbidity and mortality rates that continue to fall short of the Millennium Development Goals. Following evidence of increased utilization and improved health outcomes under free care, many African countries have recently fully or partly abolished user fees. Arguably, however, free care can lead to overuse and moral hazard, for example by reducing prevention efforts. There is a tension between subsidizing care to reduce barriers to access arising from market failures, and maintaining the role of prices in efficiently directing resources to those who value them most.The goal of this project is to study the effect of providing free healthcare and free health worker visits on three important decisions parents make for the health of their children: the time they wait before seeking care in an acute spell of illness, use of preventive care, and the use of formal vs. informal sector care. The combination of health worker visits with free care has the potential to increase access to care for poor families while reducing the inefficiencies associated with abolishing user fees - such as the overuse of primary care and the underuse of preventative care: health workers may provide better information to parents about the need for care, and also 'nudge' them towards better healthcare practices. We study the interaction of these policies with three key characteristics of households which may lead parents to underuse care for their children if they face the market price: financial constraints and an inability to borrow or save; insufficient information about health and healthcare; and the possibility that parents' spending priorities differ from those of a policymaker. The channels through which policies affect decisions are important in understanding the efficiency gains and losses from abolishing user fees and the potential of health workers to counteract some of these losses.The data for this project comes from a randomized controlled trial (RCT) conducted in a peri-urban area of Bamako, Mali. The RCT consists of two interventions; free primary care for children and free health worker visits. For each child we collect uniquely detailed data on socio-economic background as well as a complete health history over 10 weeks - detailing on a daily basis all symptoms that a child exhibits, and all healthcare sought by the mother. This data allows us to study in detail how free healthcare and health worker visits affect the healthcare behaviors of parents, and how the effects depend on the household's financial resources, its knowledge and beliefs about health issues, and its preference. The health worker intervention is in this context particularly interesting because it may on the one hand be able to address inefficiencies more directly and therefore be a viable alternative to free care, and on the other it may provide a means to counteract some of the inefficiencies of free care.Our study focuses on the effect of policy on the healthcare choices that families make, as well as on healthcare outcomes. Because of this, it will help us to understand the constraints that prevent different types of families from obtaining high quality care. This in turn will allow us to develop a model which we can used to estimate the impact of policies other than those we test directly - for example a partial abolition of fees, or means tested subsidies. In this way, our approach will make a significant contribution to the evidence-based design of healthcare policy