Plain English Summary
Background and study aims
Surgical access is critically important for strong health systems. Although 30% of the world’s disease burden is surgical, five billion people are unable to access safe, affordable, and timely surgical care. An estimated 143 million necessary surgical procedures are not done every year.
Barriers to accessing surgical care are especially high among the poor worldwide and in low- and middle-income countries (LMICs).
A 2017 retrospective study of surgical patients in West Africa found that they were almost twice as likely to show up for their scheduled surgery if their transportation costs were paid for. Vouchers for transportation have also been successful at increasing facility delivery for mothers in Bangladesh, although the voucher system itself proved difficult to administer.
Cash transfers, in which participants are given small amounts of cash in exchange for salutary behavior, are simpler to administer than vouchers and have shown success in health, nutrition, and education. Cash transfers have not yet been studied in surgery.
Building on a prior study of cash transfers for surgical patients in Guinea, this paper undertook a randomized, controlled trial (RCT) of a cash transfer for surgical patients in the country. We hypothesized that cash transfers would improve patient compliance and that, specifically, cash transfers given before patients faced the barrier of transportation costs would have a significant positive effect.
Who can participate?
Any patient who had been determined to be eligible for surgery by a specialized surgical screening team. There was no age limit, although if the patient was a child, the parent was the participant.
What does the study involve?
Participants in this study were randomized to three trial arms. Group 1 patients received the cash transfer conditional on their arrival for their surgery. Patients in Group 2 received the transfer as a mobile banking deposit 2 – 4 days prior to the day they were scheduled to leave their homes to come to the screening city for transportation to Conakry. The transfer was “labelled” with a concurrent text message. Patients in the control arm received a bag of food and staples on the day of enrollment. No further assistance was given toward their transportation costs.
What are the possible benefits and risks of participating?
Benefits: The patients would be receiving free surgery plus a cash transfer.
Risks: Aside from the minimal risk of unmasking of patient information, no other risks were likely to occur.
Where is the study run from?
Mercy Ships, a surgical charity operating a hospital ship at Conakry (Guinea)
When is the study starting and how long is it expected to run for?
January 2017 to June 2019
Who is funding the study?
Damon Runyon Cancer Research Foundation (USA)
Who is the main contact?
Prof. Mark Shrime
Cash transfers may decrease the no-show rate for surgical patients in low-resource settings: A randomized trial
Cash transfers will improve patient compliance with scheduled surgery and, specifically, cash transfers given before patients faced the barrier of transportation costs would have a significant positive effect.
Approved 12/06/2017, Massachusetts Eye and Ear Infirmary (Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA; +1 617 523 7900; firstname.lastname@example.org), ref: 15-166H
Single center interventional single-blinded randomized trial with three arms
Primary study design
Secondary study design
Randomised parallel trial
Patient information sheet
No participant information sheet available
Utilization of surgical services by surgical patients in Guinea
"Conditional cash transfer": these patients will receive 80,000 GNF (approx €7) conditional on them arriving for their scheduled surgical appointment, whether or not the surgery actually happened.
"Unconditional cash transfer": These patients received 80,000 GNF as a mobile banking deposit 2 – 4 days prior to the day they were scheduled to leave their homes to come to the screening city for transportation to Conakry. The transfer was “labeled” with a concurrent text message. If patients in this arm did not have a cell phone or a SIM card, these were provided. All transfer costs were covered.
"Control group": Patients in the control arm received a bag of food and staples on the day of enrollment. No further assistance was given toward their transportation costs.
Patients were recruited once they had been given an appointment for their on-ship screening. Allocation proceeded via simple randomization. Slips each containing a random study identification number and group allocation were concealed in an opaque envelope. Patients drew a number from the envelope in view of the researchers, local staff, and their families. The first author, who performed the data analysis, was blinded to the allocation and randomization.
Primary outcome measure
Number of patients attending scheduled surgical appointment (measured throughout the study)
Secondary outcome measures
There are no secondary outcome measures
Overall trial start date
Overall trial end date
Reason abandoned (if study stopped)
Participant inclusion criteria
Any patient who had been determined to be eligible for surgery by a specialized surgical screening team. No age limit, although if the patient was a child, the parent was the participant.
Target number of participants
Total final enrolment
Participant exclusion criteria
No diagnosed surgical disease
Recruitment start date
Recruitment end date
Countries of recruitment
Trial participating centre
m/v Africa Mercy
Damon Runyon Cancer Research Foundation
Cancer Research Fund of the Damon Runyon-Walter Winchell Foundation, Damon Runyon, DRCRF
Funding Body Type
private sector organisation
Funding Body Subtype
Trusts, charities, foundations (both public and private)
United States of America
Results and Publications
Publication and dissemination plan
Planned publication in a high-impact peer-reviewed journal.
IPD sharing statement:
The datasets generated during and/or analysed during the current study are not expected to be made available due to lack of consent.
Intention to publish date
Participant level data
Not expected to be available
Basic results (scientific)