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

需要增加最贫穷和最脆弱人口对卫生服务的接受，以改善卫生结果，并最终减轻贫困。在过去的几十年里，人们对低收入国家卫生服务普及的主要预测因素的看法发生了许多变化。S在80年代末在大多数非洲国家引入了使用费，因为他们认为，即使是最贫穷的人也有一定的能力支付医疗费用，特别是在医疗质量高的情况下。最近，低收入国家实施了若干政策，如免除使用费、全民健康保险和财政奖励，以改善最贫穷人口的保健使用情况。尽管这些新的保健政策为研究人员提供了一个独特的机会来探讨收入对保健服务吸收的作用，但使用不适当的方法来分析影响，或在这一领域进行的随机对照试验的设计和外部有效性不佳，未能提供一些证据，说明这些间接影响收入的政策影响保健服务吸收的影响和传播渠道。我建议开展一项全面和原创的研究方案，以解决这一知识差距。利用先进的计量经济学技术，这项研究将首先调查四个低收入国家的收入和卫生设施的特点对卫生保健使用的影响。然后，我将调查赞比亚取消用户费用对接入、自付医疗费用和经济脆弱性的影响。最后，我将调查不同风险厌恶程度患者的收入对尼日利亚HIV血清不一致夫妇坚持PrEP的影响。为此，我计划开发一个小型研究项目，这是将在尼日利亚实施的PrEP示范项目的一部分，目的是调查尼日利亚遵守PrEP的决定因素。关于遵守PrEP的决定因素的调查结果将被用于设计RCT，该RCT将突出分配财政激励(现金支付与彩票)的最佳金额和最佳方式，以最大限度地发挥其对遵守PrEP的影响。因此，MRC保健经济学早期职业研究金将出版一系列关于收入在低收入国家接受治疗和预防保健服务方面的作用的论文。这项研究的结果将通过演讲、研讨会和会议向学术受众和政策制定者传播。这项提案的编制将得到一系列影响评价、经济计量技术和影响评价设计方面的培训模块的支持。

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.