Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States of America.
Department of General Surgery, University of Massachusetts, Worcester, MA, United States of America.
PLoS One. 2020 May 14;15(5):e0232761. doi: 10.1371/journal.pone.0232761. eCollection 2020.
Cash transfers are a common intervention to incentivize salutary behavior in resource-constrained settings. Many cash transfer studies do not, however, account for the effect of the size of the cash transfer in design or analysis. A randomized, controlled trial of a cash-transfer intervention is planned to incentivize appropriate surgical utilization in Guinea. The aim of the current study is to determine the size of that cash transfer so as to maximize compliance while minimizing cost.
Data were collected from nine coastal Guinean hospitals on their surgical capabilities and the cost of receiving surgery. These data were combined with publicly available data about the general Guinean population to create an agent-based model predicting surgical utilization. The model was validated to the available literature on surgical utilization. Cash transfer sizes from 0 to 1,000,000 Guinean francs were evaluated, with surgical compliance as the primary outcome.
Compliance with scheduled surgery increases as the size of a cash transfer increases. This increase is asymptotic, with a leveling in utilization occurring when the cash transfer pays for all the costs associated with surgical care. Below that cash transfer size, no other optima are found. Once a cash transfer completely covers the costs of surgery, other barriers to care such as distance and hospital quality dominate.
Cash transfers to incentivize health-promoting behavior appear to be dose-dependent. Maximal impact is likely only to occur when full patient costs are eliminated. These findings should be incorporated in the design of future cash transfer studies.
现金转移是激励资源有限环境中有益行为的常见干预措施。然而，许多现金转移研究在设计或分析中并未考虑现金转移规模的影响。计划在几内亚进行一项现金转移干预的随机对照试验，以激励适当的手术利用。本研究的目的是确定现金转移的规模，以最大限度地提高依从性，同时最大限度地降低成本。
从几内亚沿海的九家医院收集有关其手术能力和接受手术成本的数据。这些数据与有关几内亚一般人口的公开数据相结合，创建了一个预测手术利用的基于代理的模型。该模型经过验证，符合有关手术利用的现有文献。评估了从 0 到 1000000 几内亚法郎的现金转移规模，以手术依从性为主要结果。
随着现金转移规模的增加，计划手术的依从性增加。这种增加是渐近的，当现金转移支付与手术护理相关的所有费用时，利用率就会稳定。在该现金转移规模以下，没有发现其他最优值。一旦现金转移完全覆盖手术费用，其他护理障碍（如距离和医院质量）就会占据主导地位。
激励促进健康行为的现金转移似乎是剂量依赖性的。只有当完全消除患者的全部费用时，才可能产生最大的影响。这些发现应纳入未来现金转移研究的设计中。
