Evidence of a causal link between health outcomes, insurance coverage, and a policy to expand access: experimental data from children in the Philippines

In this paper, we present evidence on the health effects of a health insurance intervention targeted to poor children using data from a randomized policy experiment known as the Quality Improvement Demonstration Study. Among study participants, using a difference-in-difference regression model, we estimated a 9-12 and 4-9 percentage point reduction in the likelihood of wasting and having an infection, respectively, as measured by a common biomarker C-reactive Protein. Interestingly, these benefits were not apparent at the time of discharge; the beneficial health effects were manifest several weeks after release from the hospital.

A comparison of objective biomarkers with a subjective health status measure among children in the Philippines

Large health surveys use subjective (self-reported) and objective (biomarkers) measures to assess heath status. However, the linkage or disparity of these measures has not been systematically studied in developing countries.

METHOD

Using data from the Philippine Quality Improvement Demonstration Study, QIDS, this study evaluated the associations between General Self-Reported Health Status (GSRH) and height, weight, hemoglobin, red blood cell folate, C-reactive protein, and blood lead levels. The authors modeled each biomarker as a function of GSRH controlling for socioeconomic status and selection effects. Changes in biomarkers and GSRH in children who had previously been hospitalized were also examined.

RESULTS

GSRH independently predicted hemoglobin, C-reactive protein, stunting, and wasting. GSRH did not vary significantly with folate deficiency and blood lead levels.

CONCLUSIONS

In addition to being a measure of overall child health status, GSRH may be a useful and inexpensive screening tool for identifying children that need further health testing.

Understanding Predictors of Postdischarge Deaths: A Prospective Evaluation of Children 5 Years and Younger Discharged From Philippine District Hospitals

Background. Factors that increase likelihood of readmission or mortality postdischarge from diarrhea and pneumonia cases among children is less understood. Methods. This study investigated the deaths of 24 children from a cohort of 3275. Using logistic regression, the authors compared data from those who survived with those who died to estimate the determinants of mortality in the study population. The authors also analyzed the hospital charts and completed mortality interviews with families of the deceased children. Results. Poor quality of care significantly increased the likelihood of mortality. Sicker children, those born to less-educated mothers, and those who had longer lengths of stay also had a higher likelihood of mortality. Hospital charts corroborated findings from clinical vignettes. The mortality interviews revealed delays in seeking care from onset of symptoms. Conclusion. Quality of care contributes to postdischarge mortality and that clinical vignettes are an effective means to identify where quality can be improved.

The health and cost impact of care delay and the experimental impact of insurance on reducing delays

OBJECTIVE

To examine whether delays in seeking care are associated with worse health outcomes or increased treatment costs in children, and then assess whether insurance coverage reduces these delays.

STUDY DESIGN

We use data on 4070 children younger than 5 years from the Quality Improvement Demonstration Study, a randomized controlled experiment assessing the effects of increasing insurance coverage. We examined whether delay in care, defined as greater than 2 days between the onset of symptoms and admission to the study district hospitals, is associated with wasting or having positive C-reactive protein levels on discharge, and with total charge for hospital admission; we also evaluated whether increased benefit coverage and enrollment reduced the likelihood of delay.

RESULTS

Delay is associated with 4.2% and 11.2% percentage point increases in the likelihood of wasting (P = .08) and having positive C-reactive protein levels (P = .03), respectively, at discharge. On average, hospitalization costs were 1.9% higher with delay (P = .04). Insurance intervention results in 5 additional children in 100 not delaying going to the hospital (P = .02).

CONCLUSIONS

In this population, delayed care is associated with worse health outcomes and higher costs. Access to insurance reduced delays; thus insurance interventions may have positive effects on health outcomes.

A novel method for measuring health care system performance: experience from QIDS in the Philippines

OBJECTIVES

Measuring and monitoring health system performance is important albeit controversial. Technical, logistic and financial challenges are formidable. We introduced a system of measurement, which we call Q, to measure the quality of hospital clinical performance across a range of facilities. This paper describes how Q was developed, implemented in hospitals in the Philippines and how it compares with typical measures.

METHODS

Q consists of measures of clinical performance, patient satisfaction and volume of physician services. We evaluate Q using experimental data from the Quality Improvement Demonstration Study (QIDS), a randomized policy experiment. We determined its responsiveness over time and to changes in structural measures such as staffing and supplies. We also examined the operational costs of implementing Q.

RESULTS

Q was sustainable, minimally disruptive and readily grafted into existing routines in 30 hospitals in 10 provinces semi-annually for a period of 2(1/2) years. We found Q to be more responsive to immediate impacts of policy change than standard structural measures. The operational costs totalled USD2133 or USD305 per assessment per site.

CONCLUSION

Q appears to be an achievable assessment tool that is a comprehensive and responsive measure of system level quality at a limited cost in resource-poor settings.

An evaluation of the cost-effectiveness of policy navigators to improve access to care for the poor in the Philippines

OBJECTIVES

Even when health insurance coverage is available, health policies may not be effective at increasing coverage among vulnerable populations. New approaches are needed to improve access to care. We experimentally introduced a novel intervention that uses Policy Navigators to increase health insurance enrollment in a poor population.

METHODS

We used data from the Quality Improvement Demonstration Study (QIDS), a randomized experiment taking place at the district level in the Visayas region of the Philippines. In two arms of the study, we compared the effects of introducing Policy Navigators to controls. The Policy Navigators advocated for improved access to care by providing regular system-level expertise directly to the policy-makers, municipal mayors and governors responsible for paying for and enrolling poor households into the health insurance program. Using regression models, we compared levels of enrollment in our intervention versus control sites. We also assessed the cost-effectiveness of marginal increases in enrollment.

RESULTS

We found that Policy Navigators improved enrollment in health insurance between 39% and 102% compared to the controls. Policy navigators were cost-effective at 0.86 USD per enrollee. However, supplementary national government campaigns, which were implemented to further increase coverage, attenuated normal enrollment efforts.

CONCLUSION

Policy Navigators appear to be effective in improving access to care and their success underscores the importance of local-level strategies for improving enrollment.

Should we have confidence if a physician is accredited? A study of the relative impacts of accreditation and insurance payments on quality of care in the Philippines

It is unclear whether health provider accreditation ensures or promotes quality of care. Using baseline data from the Quality Improvement Demonstration Study (QIDS) in the Philippines we measured the quality of pediatric care provided by private and public doctors working at the district hospital level in the country's central region. We found that national level accreditation by a national insurance program influences quality of care. However, our data also show that insurance payments have a similar, strong impact on quality of care. These results suggest that accreditation alone may not be sufficient to promote high quality of care. Further improvements may be achieved with properly monitored and well-designed payment or incentive schemes.

The Quality Improvement Demonstration Study: an example of evidence-based policy-making in practice

Background

Randomized trials have long been the gold-standard for evaluating clinical practice. There is growing recognition that rigorous studies are similarly needed to assess the effects of policy. However, these studies are rarely conducted. We report on the Quality Improvement Demonstration Study (QIDS), an example of a large randomized policy experiment, introduced and conducted in a scientific manner to evaluate the impact of large-scale governmental policy interventions.

Methods

In 1999 the Philippine government proposed sweeping reforms in the National Health Sector Reform Agenda. We recognized the unique opportunity to conduct a social experiment. Our ongoing goal has been to generate results that inform health policy. Early on we concentrated on developing a multi-institutional collaborative effort. The QIDS team then developed hypotheses that specifically evaluated the impact of two policy reforms on both the delivery of care and long-term health status in children. We formed an experimental design by randomizing matched blocks of three communities into one of the two policy interventions plus a control group. Based on the reform agenda, one arm of the experiment provided expanded insurance coverage for children; the other introduced performance-based payments to hospitals and physicians. Data were collected in household, hospital-based patient exit, and facility surveys, as well as clinical vignettes, which were used to assess physician practice. Delivery of services and health status were evaluated at baseline and after the interventions were put in place using difference-in-difference estimation.

Results

We found and addressed numerous challenges conducting this study, namely: formalizing the experimental design using the existing health infrastructure; securing funding to do research coincident with the policy reforms; recognizing biases and designing the study to account for these; putting in place a broad data collection effort to account for unanticipated findings; introducing sustainable policy interventions based on the reform agenda; and providing results in real-time to policy makers through a combination of venues.

Conclusion

QIDS demonstrates that a large, prospective, randomized controlled policy experiment can be successfully implemented at a national level as part of sectoral reform. While we believe policy experiments should be used to generate evidence-based health policy, to do this requires opportunity and trust, strong collaborative relationships, and timing. This study nurtures the growing attitude that translation of scientific findings from the bedside to the community can be done successfully and that we should raise the bar on project evaluation and the policy-making process.

Associations between cognitive function, blood lead concentration, and nutrition among children in the central Philippines

OBJECTIVE

Because little is known about its effects on cognitive function among children in less-developed countries, we determined the impact of lead exposure from other nutritional determinants of cognitive ability.

STUDY DESIGN

Data were from a cross-sectional population-based stratified random sample of 877 children (age 6 months-5 years) participating in the Quality Improvement Demonstration Study we are conducting in the Philippines. With data from validated psychometric instruments, venous blood samples, and comprehensive survey instruments, we developed multi-stage models to account for endogenous determinants of blood lead levels (BLLs) and exogenous confounders of the association between BLLs and cognitive function.

RESULTS

A 1 microg/dL increase in BLL was associated with a 3.32 point decline in cognitive functioning in children aged 6 months to 3 years and a 2.47 point decline in children aged 3 to 5 years olds. BLL was inversely associated with hemoglobin and folate levels. Higher folate levels mitigated the negative association between BLL and cognitive function.

CONCLUSIONS

These population-based data suggest greater lead toxicity on cognitive function than previously reported. Our findings also suggest that folate and iron deficient children are more susceptible to the negative cognitive effects of lead. Folate supplementation may offer some protective effects against lead exposure.

Elevated blood-lead levels among children living in the rural Philippines

OBJECTIVE

Generally, lead poisoning is not considered a significant environmental hazard for children in rural areas of developing countries. With a prospectively designed policy experiment, the research community and the government are conducting a broad-based investigation to introduce and evaluate the impact of health policy reforms on children in a rural area of the Philippines - the Quality Improvement Demonstration Study (QIDS). As part of this study, we researched lead exposure in children under the age of five.

METHODS

We sampled a population of children from the Visayas region in the central Philippines, covering approximately one third of the country's geographical area. From December 2003 to September 2004, the survey collected blood lead levels (BLL) together with demographic, socioeconomic and child health data points. Supplemental field-testing among a sub-sample of the most exposed children assessed the sources of environmental lead exposure.

FINDINGS

Among children in this study, 21% (601 of 2861 children) had BLL greater than 10 microg/dl. BLL were associated independently with age, haemoglobin concentration, water source, roofing material, expenditures and history of breastfeeding. A follow-up assessment of possible environmental exposures among the sub-sample of children with elevated BLL revealed no single or predominant exposure source. Instead, there appear to be multiple potential sources, such as fossil-fuel combustion, lead paint (in or around 38% of homes) and household items.

CONCLUSION

Elevated BLL are common among children in the Visayas, and may signify an under-recognized threat to children living in rural areas of other developing nations. This setting has varied environmental sources of lead. Observed correlates of BLL may be of clinical, environmental and public health utility to identify and mitigate the consequences of lead toxicity.