Center for Health Market Innovations (CHMI)

The 8th iHEA World Congress on Health Economics kicked off yesterday in Toronto, bringing together close to 2000 participants to discuss the application of economic principles to health and health systems research. CHMI staffers are in attendance to learn and report on new findings and present a poster on the new Reported Results Initiative.

A number of Monday’s presentations highlighted the prevalence of adverse drug dispensing practices. M. Hafizur Rahman of Johns Hopkins University discussed the role of Medical Representatives (MRs) in the prescription and dispensing of medication in Bangladesh. The study found that a large proportion of the country’s village doctors rely on MRs as the primary source of information on pharmaceuticals, putting MRs in a powerful position to affect prescription practices. Furthermore, because MRs are often under pressure to increase sales, they frequently exaggerate the benefits and downplay the adverse effects of certain medications. Due to their powerful position in the pharmaceutical supply chain, the study concluded that MRs may be an untapped ally in efforts to address harmful prescription practices.

In the Nigerian context, Oladimeji Oladepo of the University of Ibadan, shared results from a study that assessed anti-malarial medicine quantity, quality, and price in the informal Patent Medical Vendor (PMV) market. The study, carried out in 6 urban and 6 rural local government areas in three Nigerian states, found that 92% of shops stocked Sulfadoxine-pyrimethamine and 72% carried Chloroquine – treatments that are no longer recommended as the 1st line drugs against malaria because of widespread resistance. Only 9% stocked ACTs. The cost of ACTs, which is higher than all other treatments, was found to be one of the factors contributing to the low stock rates.

Another enlightening session presented several studies on conditional cash transfers (CCT). CCTs aim to encourage healthy behaviors by providing cash to individuals on the condition that they carry out a given task (e.g. visit a health clinic). These studies aimed to understand the effects of CCTs, as well as discover the best ways to implement them.

In one study, presented by Damien de Walque (of the World Bank), families in Burkina Faso were provided with money in exchange for taking their children to clinics and enrolling them in school. This study found that CCTs did in fact result in better health outcomes for the children when compared with cases where money was given to the families unconditionally. However, the CCTs appeared to only have significant effects on short- to medium-term health, rather than long-term health.

The study also found that the CCTs were most effective when given to the fathers of the families, rather than the mothers.

A second study, presented by William Dow (of the UC-Berkeley School of Public Health), was the first of its kind in that its desired behavior change was a reduction in risky sexual behavior. In this study, individuals in Tanzania were provided with money every time that they tested negative for STIs during a year-long period. Ultimately, results showed that, while patients did show lower prevalence of STIs, these outcomes generally didn’t manifest until the end of the year-long study, indicating a “learning” period for individuals. In terms of long term effects, when the researchers returned to the individuals a year after the conclusion of this study, they found that the male population continued to show signs of healthy sexual behavior, while they female population returned to previous levels of STI prevalence. Clearly, CCTs show a great amount of promise, but more research must be done to better understand how to successfully implement them so that they benefit all sections of the population in the long-term.

A final session occurred on the topic of Insuring the Poor, which featured findings from research aimed at better understanding the impact of health insurance programs in developing country settings, ranging from community-based schemes to national health insurance programs. Three presenters took the stage to speak about different perspectives on the topic. Julie Shi of Boston University presented an assessment of a rural health scheme in China – the New Cooperative Medical Scheme (NCMS) – that works to reduce high out of pocket expenditures among the rural poor. The research’s findings revealed that the scheme reduced out-of-pocket expenditures mostly among the rich, while it increased service utilization among the poor.

Divya Parmar of Heidelberg University asked a slightly different question in her study of community-health insurance schemes in Burkina Faso – what are the long term effects of health insurance on the overall economic health of poor households? She determined that community health insurance tends to protect and even increase household assets (which in the absence of the scheme would be sold to cover healthcare costs), but its effects are limited and it should be viewed as an intermediary step towards universal health coverage rather than a permanent solution.

Finally, Dr. Arnab Acharya of the London School of Economics took a comprehensive look at social health insurance schemes in developing countries, with the goal of assessing whether they improve health outcomes and reduce the impoverishing effect of healthcare payments for the poorest people. His team performed a systematic review using the Cochrane methodology to examine studies using more recent developments in the literature on impact evaluation. After examining 25 studies, the team made the following general observations about the nature and impact of social health insurance schemes:

• Most insurance schemes require a co-payment, with few being fully subsidized;

• Enrolment varies, from being low in most cases to being more complete in a few cases;

• Evidence on impact is very limited in scope and questionable in quality;

• No evidence was found on changes in health status, but it was found that there is an increase in utilization of outpatient services and hospitalization

• Finally, there was weak evidence to show that health insurance actually reduces out-of-pocket health expenses.

These three sessions are a small sampling of the variety of topics covered at iHEA, and more information on these talks can be found on iHEA’s website. The 8th World Congress on Health Economics will continue until tomorrow, July 13th.

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