Leveraging social networks in demand-side health financing to improve demand for preventive services in low-income settings

有条件现金转移支付（CCT）已被证明是有效的卫生筹资工具，可以补充拉丁美洲全民健康覆盖（UHC）的努力，解决弱势群体对基本卫生服务利用不足的问题。有条件现金援助传统上针对传染病、营养或妇幼健康（CN-MCH）状况的预防行为，在改善卫生服务利用方面取得了显著成功。然而，近年来，该区域的疾病负担从非传染性疾病（CN-MCH）迅速转变为非传染性疾病（ncd），特别是心血管疾病（cvd），它现在是拉丁美洲死亡和残疾的主要原因)，以及用有限的公共预算资助全民健康覆盖工作的同时面临的挑战，提出了一个问题，即是否以及如何在解决非传染性疾病方面复制过去有条件现金转移支付的成功，并以更具成本效益的方式进行。迄今为止，这个问题在学术和政策圈中基本上被忽视了，而这正是本建议的基础。这项研究将在萨尔瓦多的一个小额信贷组织（MFI）的创新干预的背景下进行，以解决其弱势客户群体（主要是来自弱势背景的妇女）的心血管疾病风险。为了支持及时治疗其客户潜在的心血管疾病风险，小额信贷机构在圣萨尔瓦多的一家附属保健诊所提供了免费的心血管疾病风险评估。它还发起了一项短信活动，以提高客户对心血管疾病的认识，并宣传风险评估。然而，尽管做出了这些努力，在诊所接受治疗的人数非常低。拟议的研究是与小额信贷机构共同设计的，并将通过与小额信贷机构客户的形成性访谈获得信息。这些访谈将探讨心血管疾病预防保健需求的障碍和推动因素，包括社会网络的潜在影响。然后进行一项随机对照试验，首先评估简单的cct是否能有效地激励个人参加心血管疾病风险评估。然后，我们将利用小额信贷机构的集体贷款小额信贷模式（向借款人群体提供贷款）来测试不同的社会激励措施和目标策略，以提高现金转移的有效性。具体而言，我们评估了利用群体内现有的社会关系（例如，通过要求贷款小组成员鼓励目标个人参加风险评估）和针对有社会影响力的个人（贷款小组负责人）的干预措施是否可以提高简单有条件现金转移支付的整体有效性。这些不同的激励设计对风险评估、自我报告的健康行为和测量的心血管疾病风险结果（血压、BMI）的成本和影响将通过后续调查和临床记录进行评估。新的发现将传播给对加强卫生系统以应对日益增长的心血管疾病流行感兴趣的学者、决策者和从业人员的广泛受众。研究结果有望为有条件现金援助干预措施在应对这些挑战方面的潜力提供有价值的证据，并为进一步研究系统级实施类似干预措施的可行性提供信息。

Conditional cash transfers (CCT) have proved to be effective health-financing tools to complement universal health coverage (UHC) efforts in Latin America, in tackling underutilisation of essential health services among disadvantaged groups. CCTs traditionally targeted preventive behaviours for communicable, nutritional or maternal and child health (CN-MCH) conditions, with notable successes in improving health service utilisation. However, a rapid shift in the region's disease burden from CN-MCH to non-communicable diseases (NCDs) in recent years - particularly cardiovascular diseases (CVDs), which are now the leading causes of death and disability in Latin America - and concurrent challenges of financing UHC efforts with limited public budgets, raises the question of if and how past CCT successes can be replicated in tackling NCDs, and be done in more cost-effective ways. This question has been largely neglected in academic and policy circles to date, and forms the basis of this proposal. The research will take place in the context of an innovative intervention by a micro-finance organisation (MFI) in El Salvador, to tackle CVD risks among its vulnerable client population (predominantly women from disadvantaged backgrounds). To support timely treatment of potential CVD risks among its clients, the MFI has offered free CVD risk assessments at an affiliated healthcare clinic in San Salvador. It also launched a text messaging campaign to increase clients' CVD awareness, and publicise the risk assessments. Despite these efforts however, take-up of care at the clinic has been very low.The proposed study is co-designed with the MFI, and will be informed by formative interviews with the MFI's clients. These interviews will explore barriers and enablers of demand for CVD preventive care, including the potential influence of social networks. A randomised controlled trial will then be conducted to first assess whether simple CCTs can be effective in incentivising individuals to attend the CVD risk assessments. We will then leverage the MFI's group-lending micro-finance model, where loans are given to groups of borrowers, to test different social incentives and targeting strategies for improving the effectiveness of the cash transfers alone. Specifically, we assess whether appealing to existing social ties within groups (for example, by asking loan group members to encourage targeted individuals to attend the risk assessments) and targeting such interventions on socially influential individuals (loan group leaders) can enhance the overall effectiveness of simple CCTs. The costs and effects of these different incentive designs on risk assessment take-up, self-reported health behaviours, and measured CVD risk outcomes (blood pressure, BMI) will be evaluated through a follow-up survey and clinic records. Novel findings will be disseminated to a wide audience of academics, policy makers and practitioners interested in health system strengthening for tackling a growing CVD epidemic. Results are expected to contribute valuable evidence on the potential for CCT interventions in addressing these challenges, and inform further research on the feasibility of system-level implementation of similar interventions.