Supported Research Project August 07, 2017

New Evidence Strengthens Case for Universal Health Coverage in Madagascar

A study led by PIVOT research manager Dr. Andres Garchitorena offers meaningful new evidence to the global debate on Universal Health Coverage (UHC), demonstrating that removing user fees for health care can result in substantial increases in the use of services at low costs that can be scaled. The study, published in the August issue of the journal Health Affairs, draws on findings from two pilot health finance initiatives in rural Madagascar, one led by the World Bank and another by PIVOT.

In Ifanadiana District, where one in six children dies before the age of five and where more than 82% of people live in extreme poverty, exempting fees for targeted medicines and services produced striking results: increases of 65% in the use of services for all patients, 52% for children under age five, and over 25% for maternity consultations, at an average direct cost of US$0.60 per patient. These results, in such a challenging socioeconomic and health care context, provide compelling evidence that interventions for UHC can be achieved at a scalable cost level, even for extremely poor and vulnerable populations.

“The prohibitive cost of life-saving medicines remains a primary cause of health inequities. This research in Madagascar demonstrates how countries can make the moral imperative of universal health coverage a reality,” said Dr. Paul Farmer, Kolokotrones University Professor at Harvard University and co-founder of Partners In Health.

Universal health coverage aims to ensure that all people have access to needed health services without suffering financial hardship. While UHC is a national government priority in Madagascar, implementation has not been accomplished. In the meantime, patients pay directly for medicines and supplies during their care; due to high poverty rates, this means that most either forgo care entirely or access services too late, often while incurring catastrophic financial costs. Interventions like the removal of user fees are key for expanding access for rural populations, and evidence on their efficacy is critical for informing this policy, facilitating implementation, and improving service delivery and health outcomes.

The study analyzed high-resolution population-based data from a survey of 1,522 households at baseline of these interventions, as well as three years of data from 19 health centers within a government district. A detailed time-series analysis of utilization at these health facilities tracked the outcomes from the two initiatives that removed patient user fees. Dr. Garchitorena points to the unique insights offered across these data sets: “The timing of the different interventions created a quasi-experiment, allowing for a rigorous evaluation of utilization of health centers before and after the initiatives.” The results provide direct evidence for projecting the costs and impacts of removing fees at the point of service, and add to the mounting evidence that even small fees can reduce access to essential health services for the poor.

Access the abstract and full article here: