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

事实证明，有条件现金转移支付是补充拉丁美洲全民医保努力的有效卫生筹资工具，可解决弱势群体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、营养或妇幼保健状况的预防行为，在提高保健服务利用率方面取得了显著成功。然而，近年来，该区域的疾病负担迅速从新生儿-妇幼保健转向非传染性疾病-特别是心血管疾病，目前心血管疾病是拉丁美洲死亡和残疾的主要原因-以及同时面临的以有限的公共预算资助全民健康覆盖工作的挑战，提出了在应对非传染性疾病方面是否以及如何复制过去有条件现金援助的成功的问题，并以更经济的方式完成。这一问题迄今在学术界和政策界基本上被忽视，并构成了这一建议的基础。这项研究将在萨尔瓦多萨尔瓦多的一个小额供资组织采取创新干预措施的背景下进行，以应对其弱势客户群体（主要是来自弱势背景的妇女）中的心血管疾病风险。为了支持及时治疗其客户中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医疗诊所提供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，诊所的护理接受率仍然非常低。拟议的研究是与MFI共同设计的，并将通过对MFI客户的形成性采访来了解情况。这些访谈将探讨CVD预防护理需求的障碍和推动因素，包括社交网络的潜在影响。然后将进行一项随机对照试验，首先评估简单的CCT是否能有效激励个人参加CVD风险评估。然后，我们将利用小额信贷机构的团体贷款小额信贷模式，向借款人团体提供贷款，以测试不同的社会激励措施和目标战略，以提高现金转移的有效性。具体来说，我们评估是否呼吁现有的社会关系的群体（例如，通过要求贷款组成员，以鼓励目标个人参加风险评估），并针对社会有影响力的个人（贷款组领导人），可以提高简单的CCT的整体效果。这些不同激励设计对风险评估接受、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诊所记录进行评估。新的研究结果将传播给广大的学者，政策制定者和从业人员感兴趣的卫生系统加强应对日益严重的心血管疾病流行病。研究结果有望为有条件现金援助干预措施应对这些挑战的潜力提供宝贵证据，并为进一步研究系统一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.