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

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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