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

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.

A greater health systems focus on prevention and early detection of diseases is necessary to address the growing burden of cardiovascular diseases (CVD) in Latin America. In partnership with a micro-finance organisation (MFI) in El Salvador, this project will provide new evidence on the scope for well-designed and targeted conditional cash transfers (CCTs) in improving use of free screening services for CVD risks among vulnerable individuals in low-income settings.

The research is informed by a theory of demand for preventive services based on the widely-cited Health Belief Model (HBM), highlighting a role for psychosocial factors (including social influences) in preventive behaviours, and elaborated through formative in-depth interviews with the MFI's clients.

To test the effectiveness of CCTs in improving take-up of free CVD risk screenings, a randomised controlled trial will be conducted with the MFI's loan groups. 300 loan groups (with pre-existing social ties) will be randomised to four arms. One individual will be selected from each group for targeting in the intervention, to evaluate the relative effects of simple CCTs, CCTs enhanced with social incentives (leveraging individuals' pro-social concerns), and CCTs employing different strategies for selecting targeted individuals (random group members vs. socially influential loan group leaders). Primary outcomes of interest are risk-screening attendance, other self-reported health behaviours and measured CVD risk outcomes (blood pressure, BMI) at follow-up. Outcomes will be measured through a baseline and follow-up survey of all loan group members, and using health clinic records.

The relative effectiveness (and cost-effectiveness) of the different CCT designs will be assessed by comparing outcomes and implementation costs in the CCT treatment arms and the no-CCT control arm.

The growing cardiovascular disease (CVD) epidemic in low and middle-income countries (LMIC) demands innovative approaches to ensure both cost-effective delivery and sufficient take-up of screening services for modifiable CVD risks. By generating evidence on both novel demand-side health financing approaches and a systematic CVD risk screening intervention targeting disadvantaged groups, this research holds potential to ultimately benefit patient health in LMIC. Immediate beneficiaries will be:

1) Policymakers in El Salvador and other LMIC, and international development stakeholders (advisors, donors, implementers e.g. PAHO, IDB). Research outputs will inform health policies targeting CVDs, and non-communicable diseases (NCD) in general, in LMIC:
- Beneficiaries are familiar with the use and effects of conditional cash transfers (CCTs) for communicable, nutritional, maternal and child health (CN-MCH) conditions; however, evidence on the application of CCTs to NCDs is scarce. This research will contribute rigorous evidence on the desirability, effects and limitations of CCTs in facilitating CVD risk screening in low-income settings, and the scope for social incentives in enhancing conventional CCTs.
- The application of WHO's total CVD risk assessment protocol will generate evidence on the effectiveness of these service delivery guidelines, and the cost-effectiveness of systematic screening for CVD risks in LMIC settings.
- The study's embedding in a local micro-finance NGO's healthcare initiative will contribute insights to policy discourse on integrating grass-roots NGOs for expanding health system capacity to serve disadvantaged, hard-to-reach populations. As evidenced in the co-design of this research, such organisations have a wealth information on the health needs of the poor and established mechanisms for reaching them consistently over time, which may facilitate delivery of targeted health interventions.

We expect results to inform beneficiary decisions to invest in larger pilots or further research on the use of CCTs and systematic risk screening approaches for NCDs in low-resource settings. Engagement with these beneficiaries will occur at 2 stages: i) consultation in research design, and ii) during results dissemination, through targeted policy-friendly outputs. The research team and partnering NGO (ASEI)'s regional and international networks will facilitate engagement; for instance, the founder of ASEI (Ricardo Segovia) is a partner at the Central American Healthcare Initiative (CAHI), which offers a platform and relevant contacts for regional results dissemination efforts.

2) Micro-finance organisations (MFI), including ASEI. MFIs are increasingly integrating health services in their operations for sustainability reasons. The research will support their understanding of the factors driving preventive healthcare use among clients, and novel ways to leverage their group-lending models to improve clients' health-seeking behaviours. Analysis of the CVD prevention initiative will specifically benefit ASEI, and inform its plans to refine and roll out the initiative beyond San Salvador. ASEI is engaged in co-designing the study, and efforts will be taken to build relevant findings into MFIs' operations through the dissemination and capacity-building platforms offered by CAHI.

3) Academic community. This group includes health systems and public health researchers, development and health economists, and students. We expect the study to advance academic research on health systems strengthening for the prevention and early detection of NCDs, and contribute to qualitative and experimental research on determinants of demand for preventive care and social influences on health-seeking behaviours in LMIC. Beneficiaries will be engaged through seminars and presentations at relevant academic conferences, and teaching programmes at the LSE and ESEN. All primary data collected will also be made publicly available.