The costs of care

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The scene in Korle Bu Hospital, in the traffi c-choked city of Accra, Ghana, was one of the most shocking I have witnessed. In a side room off the third fl oor paediatric intensive care unit, I counted 27 newborn babies lying on four black mattresses on the fl oor. They were being held hostage by the hospital against payment of bills for their care. Their mothers, who had no hope of raising these sums, were allowed into the “baby prison” every 3 hours to feed them, before being banished again. Some babies had been detained for months. That was in 2005, but the image is etched on my memory as the clearest example, although admittedly extreme, of the harm done by charging patients for medical services that are both unavoidable and unpredictable. Medical charities such as Save the Children have lobbied vigorously for the removal of charges, which are seen as a deterrent to care, and governments of some developing countries have introduced free access as a way of boosting their nation’s health. Earlier this year that assumption was challenged by a fascinating study in Ghana of over 2000 households with children under 5 years old (PLoS Med 2009; 6: e1000007). Half were given free care and the remainder were made to pay, the normal practice in the region. The results showed, unexpectedly, that providing free care did not improve health, although it led to a slight increase in use of medical services. Anaemia, haemoglobin concentrations, parasite prevalence, and deaths were similar in both groups. What is the explanation? The authors suggest the increase in use of medical services by those with free care may have been too modest to make a diff erence. Alternatively, the other costs of treatment in Ghana such as travel, and taking time off work, were more important than the small charge—12 000 cedis (about US$1) for malaria treatment, for example. The issue of user fees is a fraught one. There is a strong equity argument for removing them and there may be other unmeasured eff ects. Clearly, there can be no justifi cation for the ludicrous fees imposed on mothers in the intensive care unit at Korle Bu Hospital. But this fi nding is a reminder that we must not let our hearts rule our heads. In terms of maximising bang for bucks, abolishing user fees may not be the best way of increasing health gain. The other barriers to treatment need closer investigation fi rst.