Does Free Public Health Care Increase Utilization and Reduce Spending? Heterogeneity and Long Term Effects.

Zambia removed user fees in publicly supported-government and faith based- health facilities in 54 out of 72 districts in 2006. This was extended to rural areas of previously unaffected districts in 2007. The natural experiment provided by the step-wise implementation of the removal policy and five waves of nationally representative household survey data enables us to study the impact of the removal policy on utilization and household health expenditure. We find that the policy increased overall use of health services in the short term and the effects were sustained in the long term. The increases were higher for individuals whose household heads were unemployed or had no or less education. The policy also led to a small shift in care seeking from private to publicly supported facilities, an effect driven primarily by individuals whose household heads were either formally employed or engaged in farming. The likelihood of incurring any spending reduced, although this weakened slightly in the long term. At the same time, there was an upward pressure on conditional health expenditure, i.e., expenditure was higher after removal of fees for those who incurred any spending. Hence, total (unconditional) household health expenditure was not significantly affected.

Variation in practice: a questionnaire survey of how congruence in attitudes between doctors and patients influences referral decisions.

BACKGROUND: There is a well-known and partly unexplained variation in referral rates among general practitioners (GPs). GPs who are positive toward shared decision making refer less to secondary care, but how congruence in attitudes between doctors and patients influences referral rates has not been investigated. In this study, the authors analyze whether congruence in attitudes between the GP and patients toward shared decision making affects the GP's referral rate. METHODS: Questionnaire survey was distributed by 56 Norwegian GPs, each to 50 consulting patients. The level of congruence in attitudes toward shared decision making of GPs and corresponding patients was measured by the Patient-Practitioner Orientation Scale. The survey also included self-reported referral rates. RESULTS: In total, 1268 patients (45%) returned the questionnaires. Respondents were eliminated if they did not fully answer the questionnaire, resulting in a working sample of 835 patients. The authors found that congruence of attitudes toward shared decision making between the GP and patients had a negative effect on referral rate. CONCLUSION: In this study, congruence of attitudes toward shared decision making between GPs and patients influences referral decisions, indicating that matching attitudes may enhance the effort to solve the medical problem within the GPs' practice (i.e., doctor-patient interaction explains some of the variation in practice). The study supports the policy argument that, if possible, health authorities should enhance the possibilities for patients to choose a GP of matching attitudes.

Explaining changes in child health inequality in the run up to the 2015 Millennium Development Goals (MDGs): The case of Zambia.

BACKGROUND: Child health interventions were drastically scaled up in the period leading up to 2015 as countries aimed at meeting the 2015 target of the Millennium Development Goals (MDGs). MDGs were defined in terms of achieving improvements in average health. Significant improvements in average child health are documented, but evidence also points to rising inequality. It is important to investigate factors that drive the increasing disparities in order to inform the post-2015 development agenda of reducing inequality, as captured in the Sustainable Development Goals (SDGs). We investigated changes in socioeconomic inequality in stunting and fever in Zambia in 2007 and 2014. Unlike the huge literature that seeks to quantify the contribution of different determinants on the observed inequality at any given time, we quantify determinants of changes in inequality. METHODS: Data from the 2007 and 2014 waves of the Zambia Demographic and Health Survey (DHS) were utilized. Our sample consisted of children aged 0-5 years (n = 5,616 in 2007 and n = 12,714 in 2014). We employed multilevel models to assess the determinants of stunting and fever, which are two important child health indicators. The concentration index (CI) was used to measure the magnitude of inequality. Changes in inequality of stunting and fever were investigated using Oaxaca-type decomposition of the CI. In this approach, the change in the CI for stunting/fever is decomposed into changes in CI for each determinant and changes in the effect-measured as an elasticity-of each determinant on stunting/fever. RESULTS: While average rates of stunting reduced in 2014 socioeconomic inequality in stunting increased significantly. Inequality in fever incidence also increased significantly, but average rates of fever did not reduce. The increase in the inequality (CI) of determinants accounted for the largest part (42.5%) of the increase in inequality of stunting, while the increase in the effect of determinants explained 35% of the increase. The determinants with the greatest total contribution (change in CI plus change in effect) to the increase in inequality of stunting were mother's height and weight, wealth, birth order, facility delivery, duration of breastfeeding, and maternal education. For fever, almost all (86%) the increase in inequality was accounted for by the increase in the effect of determinants of fever, while the distribution of determinants mattered less. The determinants with the greatest total contribution to the increase in inequality of fever were wealth, maternal education, birth order and breastfeeding duration. In the multilevel model, we found that the likelihood of a child being stunted or experiencing fever depends on the community in which they live. CONCLUSIONS: To curb the increase in inequality of stunting and fever, policy may focus on improving levels of, and reducing inequality in, access to facility deliveries, maternal nutrition (which may be related to maternal weight and height), complementary feeding (for breastfed children), wealth, maternal education, and child care (related to birth order effects). Improving overall levels of these determinants contribute to the persistence of inequality if these determinants are unequally concentrated on the well off to begin with.

Access to primary health care and health outcomes: the relationships between GP characteristics and mortality rates.

This paper analyses the impact of economic conditions and access to primary health care on health outcomes in Norway. Total mortality rates, grouped into four causes of death, were used as proxies for health, and the number of general practitioners (GPs) at the municipality level was used as the proxy for access to primary health care. Dynamic panel data models that allow for time persistence in mortality rates, incorporate municipal fixed effects, and treat both the number and types of GPs in a district as endogenous were estimated using municipality data from 1986 to 2001. We reject the significant relationship between mortality and the number of GPs per capita found in most previous studies. However, there is a significant effect of the composition of GPs, where an increase in the number of contracted GPs reduces mortality rates when compared with GPs employed directly by the municipality.

Prioritization and the elusive effect on welfare - a Norwegian health care reform revisited.

The Faster Return to Work (FRW) scheme that Norwegian authorities implemented in 2007 is an example of a policy that builds on the human capital approach. The main idea behind the scheme is that long waiting times for hospital treatment lead to unnecessarily long periods of absence from work. To achieve a reduction in average sickness absence duration, the allocation of FRW funds and new treatment capacity is exclusively aimed at people on sick leave. Many countries have allocated funds to reduce waiting times for hospital treatment and research shows that more resources allocated to the hospital sector can reduce waiting times. Our results support this as the FRW scheme significantly reduces waiting times. However, on average the reduction in waiting times is not transformed into an equally large reduction in the sickness absence period. We find significant difference in the effects of FRW on length of sick leave between surgical and non-surgical patients though. The duration of sick leave for FRW patients undergoing surgical treatment is approximately 14 days shorter than for surgical patients on the regular waiting list. We find no significant effect of the scheme on length of sick leave for non-surgical patients. In sum, our welfare analysis indicates that prioritization of the kind that the FRW scheme represents is not as straightforward as one would expect. The FRW scheme costs more than it contributes in reduced productivity loss. We base our analyses on several different econometric methods using register data on approximately 13,500 individuals over the period 2007-2008.

A low-key social insurance reform--effects of multidisciplinary outpatient treatment for back pain patients in Norway.

This paper estimates treatment effects for back pain patients using observational data from a low-key social insurance reform in Norway. Using a latent variable model, we estimate the average treatment effect (ATE), the average effect of treatment on the treated (TT), and the distribution of treatment effects for multidisciplinary outpatient treatment at three different locations. To estimate these treatment effects, we use a discrete-choice model with unobservables generated by a factor structure model. Distance to the nearest hospital (in kilometres) is used as an instrument in estimating the different treatment effects. We find a positive effect of treatment of around 6 percentage points on the probability of leaving the sickness benefits scheme after allowing for selection effects and full heterogeneity in treatment effects. We also find that there are sound arguments for expanding the multidisciplinary outpatient programme for treating back pain patients.

Overworked? On the relationship between workload and health worker performance.

The shortage of health workers in many low-income countries poses a threat to the quality of health services. When the number of patients per health worker grows sufficiently high, there will be insufficient time to diagnose and treat all patients adequately. This paper tests the hypothesis that high caseload reduces the level of effort per patient in the diagnostic process. We observed 159 clinicians in 2095 outpatient consultations at 126 health facilities in rural Tanzania. Surprisingly, we find no association between caseload and the level of effort per patient. Clinicians appear to have ample amounts of idle time. We conclude that health workers are not overworked and that scaling up the number of health workers is unlikely to raise the quality of health services. Training has a positive effect on quality but is not in itself sufficient to raise quality to adequate levels.

Does variation in general practitioner (GP) practice matter for the length of sick leave? A multilevel analysis based on Norwegian GP-patient data.

In Norway, as in many countries, the national insurance system is under economic stress from demographic change impacting on the pensions versus contributions balance, and an increasing number of disability and sickness benefit claimants. The general practitioner (GP) is responsible for assessing work capacity and issuing certificates for sick leave based on an evaluation of the patient. Although many studies have analyzed certified sickness absence and predictive factors, no studies assess its variation between patients, GPs or geographical areas within a multilevel framework. Using a rich Norwegian matched patient-GP data set and employing a multilevel random intercept model, the study attempts to disentangle patient, GP and municipality-level variation in the certified sickness absence length for Norwegian workers in 2003. We find that most observed patient and GP characteristics are significantly associated with the length of sick leave (LSL) and medical diagnosis is an important observed factor explaining certified sickness durations. However, 98% of the unexplained variation in the LSL is attributed to patient factors rather than influenced by variation in GP practice or differences in municipality-level characteristics. Our findings indicate that GPs practice variation does not matter much for the patients' LSL. Our results are compatible with a high degree of patient involvement in current general practice. Based on this understanding one may infer that GPs play an advocate role for their patients in Norway, where the patients' own wishes are important when decisions are made.

Patient involvement in clinical decision making: the effect of GP attitude on patient satisfaction.

OBJECTIVE: This study investigates general practitioners' (GPs) and patients' attitudes to shared decision making, and how these attitudes affect patient satisfaction. BACKGROUND: Sharing of information and decisions in the consultation is largely accepted as the ideal in general practice. Studies show that most patients prefer to be involved in decision making and shared decision making is associated with patient satisfaction, although preferences vary. Still we know little about how the interaction of GP and patients' attitudes affects patient satisfaction. One such study was conducted in the USA, but comparative studies are lacking. DESIGN: Questionnaire survey distributed through GPs. SETTING AND PARTICIPANTS: The results are based on the combined questionnaires of 41 GPs and 829 of their patients in the urban municipality of Bergen in the western part of Norway. Main variables studied The data were collected using a nine-item survey instrument constructed to measure attitudes towards patient involvement in medical consultations. The patients were also asked to rate their satisfaction with their GP. RESULTS AND CONCLUSIONS: The patients had a strong preference for shared decision making. The GPs also generally preferred shared decision making, but to a lesser degree than the patients, which is the opposite of the findings of the US study. There was a positive effect of the GP's attitude towards shared decision making on patient satisfaction, but no significant effect of congruence of attitudes between patient and GP on patient satisfaction. The suggested explanation is that GPs that are positive to sharing decisions are more responsive to patients' needs and therefore satisfy patients even when the patient's attitude differs from the GPs' attitude. Hence, although some patients do prefer a passive role, it is important to promote positive attitudes towards patient involvement in medical consultations.