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

发展中国家，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--尤其是考虑到儿童发病率和死亡率仍达不到千年发展目标。有证据表明，在免费护理下，使用率增加并改善了健康结果，许多非洲国家最近完全或部分取消了使用费。然而，可以说，免费护理可能会导致过度使用和道德风险，例如通过减少预防努力。在补贴护理以减少市场失灵造成的准入障碍和保持价格在有效地将资源引导到最珍视它们的人方面之间存在紧张关系。该项目的目标是研究提供免费医疗保健和免费卫生工作者来访对父母为孩子的健康做出的三个重要决定的影响：他们在急性疾病期间寻求护理的等待时间，预防性护理的使用，以及使用正式与非正式部门的护理。卫生工作者就诊与免费护理相结合，有可能增加贫困家庭获得护理的机会，同时减少与取消使用者收费相关的低效--例如过度使用初级保健和未充分利用预防性保健：卫生工作者可能会向父母提供更好的关于护理需求的信息，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之间的相互作用，这些特征可能会导致父母在面对市场价格时对孩子的照顾不足：财政紧张，无法借贷或储蓄；关于健康和医疗保健的信息不足；父母的支出优先事项与政策制定者不同的可能性。政策影响决策的渠道对于了解取消用户收费的效率收益和损失以及卫生工作者抵消其中一些损失的潜力非常重要。该项目的数据来自马里巴马科郊区进行的一项随机对照试验(RCT)。RCT由两项干预措施组成：为儿童提供免费初级保健和免费探视卫生工作者。对于每个孩子，我们收集了关于社会经济背景的独特详细数据以及超过10周的完整健康史-每天详细说明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和医护人员访问如何影响父母的医疗行为，以及这种影响如何取决于家庭的经济来源、对健康问题的知识和信念以及他们的偏好。在这种情况下，卫生工作者的干预特别有趣，因为一方面它可能能够更直接地解决低效问题，因此是免费医疗的可行替代方案，另一方面它可能提供一种手段来抵消自由医疗的一些低效。我们的研究重点是政策对家庭做出的医疗选择以及医疗结果的影响。正因为如此，这将有助于我们了解阻碍不同类型家庭获得高质量护理的制约因素。这反过来将使我们能够开发一个模型，我们可以用它来估计我们直接测试的政策以外的政策的影响--例如部分取消收费，或经济状况调查补贴。通过这种方式，我们的方法将对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