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

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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.