Table3_Impact of cash transfer programs on healthcare utilization and catastrophic health expenditures in rural Zambia: a cluster randomized controlled trial.docx

BackgroundNearly 100 million people are pushed into poverty every year due to catastrophic health expenditures (CHE). We evaluated the impact of cash support programs on healthcare utilization and CHE among households participating in a cluster-randomized controlled trial focusing on adolescent childbearing in rural Zambia.
Methods and findingsThe trial recruited adolescent girls from 157 rural schools in 12 districts enrolled in grade 7 in 2016 and consisted of control, economic support, and economic support plus community dialogue arms. Economic support included 3 USD/month for the girls, 35 USD/year for their guardians, and up to 150 USD/year for school fees. Interviews were conducted with 3,870 guardians representing 4,110 girls, 1.5–2 years after the intervention period started. Utilization was defined as visits to formal health facilities, and CHE was health payments exceeding 10% of total household expenditures. The degree of inequality was measured using the Concentration Index. In the control arm, 26.1% of the households utilized inpatient care in the previous year compared to 26.7% in the economic arm (RR = 1.0; 95% CI: 0.9–1.2, p = 0.815) and 27.7% in the combined arm (RR = 1.1; 95% CI: 0.9–1.3, p = 0.586). Utilization of outpatient care in the previous 4 weeks was 40.7% in the control arm, 41.3% in the economic support (RR = 1.0; 95% CI: 0.8–1.3, p = 0.805), and 42.9% in the combined arm (RR = 1.1; 95% CI: 0.8–1.3, p = 0.378). About 10.4% of the households in the control arm experienced CHE compared to 11.6% in the economic (RR = 1.1; 95% CI: 0.8–1.5, p = 0.468) and 12.1% in the combined arm (RR = 1.1; 95% CI: 0.8–1.5, p = 0.468). Utilization of outpatient care and the risk of CHE was relatively higher among the least poor than the poorest households, however, the degree of inequality was relatively smaller in the intervention arms than in the control arm.
ConclusionsEconomic support alone and in combination with community dialogue aiming to reduce early childbearing did not appear to have a substantial impact on healthcare utilization and CHE in rural Zambia. However, although cash transfer did not significantly improve healthcare utilization, it reduced the degree of inequality in outpatient healthcare utilization and CHE across wealth groups.
Trial Registrationhttps://classic.clinicaltrials.gov/ct2/show/NCT02709967, ClinicalTrials.gov, identifier (NCT02709967).

背景
每年约有1亿人因灾难性卫生支出（catastrophic health expenditures, CHE）陷入贫困。本研究依托一项针对赞比亚农村青少年生育问题的整群随机对照试验（cluster-randomized controlled trial），评估现金支持项目对受试家庭的医疗服务利用情况及灾难性卫生支出的影响。

方法与结果
本试验于2016年从12个县区的157所农村学校招募入读七年级的青春期少女，共设置对照组、经济支持组以及经济支持联合社区对话组3个研究组。经济支持方案包括：为受试少女提供每月3美元的补贴，为其监护人提供每年35美元的补贴，以及最高每年150美元的学费资助。干预启动1.5至2年后，研究团队对代表4110名少女的3870名监护人开展了访谈。
本研究将医疗服务利用定义为前往正规医疗机构就诊，将灾难性卫生支出定义为医疗支出占家庭总支出比例超过10%的情况。采用集中指数（Concentration Index）衡量不平等程度。
对照组中，前一年有26.1%的家庭使用过住院医疗服务，经济支持组为26.7%（相对风险（Relative Risk, RR）=1.0；95%置信区间（95% confidence interval, 95% CI）：0.9–1.2，p=0.815），联合组为27.7%（RR=1.1；95%CI：0.9–1.3，p=0.586）。前4周的门诊医疗服务利用率方面，对照组为40.7%，经济支持组为41.3%（RR=1.0；95%CI：0.8–1.3，p=0.805），联合组为42.9%（RR=1.1；95%CI：0.8–1.3，p=0.378）。对照组中约10.4%的家庭发生了灾难性卫生支出，经济支持组为11.6%（RR=1.1；95%CI：0.8–1.5，p=0.468），联合组为12.1%（RR=1.1；95%CI：0.8–1.5，p=0.468）。
相较于最贫困家庭，非贫困家庭的门诊医疗服务利用率及灾难性卫生支出风险相对更高；但干预组的不平等程度相较于对照组更低。

结论
仅开展经济支持，或联合社区对话以降低早育行为，均未对赞比亚农村地区的医疗服务利用及灾难性卫生支出产生显著影响。不过，尽管现金支持未显著提升医疗服务利用率，但其缩小了不同财富阶层在门诊医疗服务利用及灾难性卫生支出方面的不平等程度。

试验注册
https://classic.clinicaltrials.gov/ct2/show/NCT02709967，ClinicalTrials.gov，标识符为NCT02709967。