A presentation to the ACERH Policy Forum held in Perth on 20 February 2009 Renata Hasanova

1. The effectiveness of financial incentives to encourage kidney donation:New evidence from Australia A presentation to the ACERH Policy Forumheld in Perth on 20 February 2009 Renata Hasanova Jim Butler ACERH (ANU)

2. Overview • Effect of payment on supply • Possible supply alternatives • The Survey: Elicitation Approach • The Survey: Sample, Controls & Eligibility • The Survey: Results 5.1 Post Mortal Donation Response 5.2 Living Donation Response 6. Summary: Emerging Trends 7. Further Steps

3. 1. Effect of payment on supply

4. 2. Possible Supply Alternatives

5. Registered Donors: Shift in Supply and Inflated Costs Question to Registered Donors If there was a scheme set up for people to receive payment for registering to donate a kidney, what do you think you would do? Possible Responses Take your name off the organ donor register OFFENDED ALTRUIST Continue to be registered as a kidney donor and would NOT EXPECT to receive some payment if others were receiving it ALTRUIST Continue to be registered as a kidney donor and would EXPECT to receive some payment if others were receiving it Monetary Induced Supply INFLATED COSTS 3. The Survey: Elicitation Approach

6. Not Registered as Kidney Donors: Shift in Potential Supply Question Just to confirm, are you comfortable answering questions about payment for kidneys? Possible Responses ‘Yes’ Monetary Induced Supply ‘No’ → Reason? I find it unethical / I don’t agree with payment for organs Potentially OFFENDED ALTRUIST Opposed to any form of transplant I don’t want to think about it right now Don’t know Other 3. The Survey: Elicitation Approach

7. 3. The Survey: Elicitation Approach • Anchoring Bias vs Open-Ended wide incomparable intervals • Pilot testing • Strategic behaviour is minimized by using only two bids • Personal evaluation at the end “What is the lowest amount you would expect to become (to continue) a registered kidney donor?”: provides consistency check

8. Initial Sample 1,500 respondents (completed interviews) 50/50 gender split Age groups: 300 respondents in each of 5 age groups 18 – 24 25-34 35-44 45 – 54 55-65 No known serious medical conditions preventing donation(self assessed) Australian Citizen or Permanent Resident Living Donation restricted to:- In “good”, “very good” and “excellent” health (self assessed)- 18 to 54 years old 4. The Survey: Sample, Controls & Eligibility

9. Also control for: Household Income, Size and Composition (children) Country of Birth and Ethnicity Work status and Education Attitudes towards Donation: support/oppose & how likely to register Current/Past Blood Donor Know someone who has donated an organ or had a transplant or is on a waiting list Health care worker Religion (if influenced) 4. The Survey: Sample, Controls & Eligibility

10. 5. The Survey: Results

11. 5.1 The Survey: Post Mortal Donation Response

12. 5.1 The Survey: Post Mortal Donation Response

13. 5.1 The Survey: PM Donation Response Changes in Supply RKD = Registered Kidney Donor; NR = Not Registered Kidney Donor

14. 5.1 The Survey: PM Donation Response Supply Schedules RKD = Registered Kidney Donor; NR = Not Registered Kidney Donor

15. 5.1 The Survey: PM Donation Response Sample SupplyCurves 10,000 PM II PM I 5,000 1,000 920 1,013 1,081 1,093 915 926 1,000 1,050 1,057

16. Question … Thinking about what I have just told you about a living kidney donation, would you be willing to consider donating a kidney to someone you didn’t know without being paid? Answers YES NO DON’T KNOW 278 745 93 25% 67% 8% Sample = 1,116, age group 18-54, in good health or better 5.2 The Survey: Living Donation Response

17. Question … are you comfortable answering questions about payment for a live kidney donation to someone you did not know? Answer NO YES 80 (7%) 1,036 (93%) I find it unethical/don’t agree with payment for organs 35 (6) Opposed to any form of transplant 1 I don’t want to think about it now 18 Other/Don’t know 26 5.2 The Survey: Living Donation Response

18. 5.2 The Survey: Living Donation Response

19. 5.2 The Survey: Living Donation Response RKD = Registered Kidney Donor; NR = Not Registered Kidney Donor

20. It is unlikely that financial incentives for kidney donations will trigger the Offended Altruist effect Less than 1% of currently registered donors will withdraw their registration in “protest” 2.2% of respondents who are not currently registered disagree with payments for organs Current Altruists do not expect to be paid for their donation even if a payment system is introduced Survey results suggest stronger preferences for the Beneficiary-Paid system. It also reduces uncertainty around costs to the system The resulting increase in supply – not adjusted for the mortality rates – is about 25-30% at the maximum cost of $5,000 per kidney 6. Summary: Emerging TrendsA. Compensated Post Mortal Donation

21. Financial Incentives have a positive impact on supply of kidneys However brings a stronger (than in PM setting) offended altruist effect Based on collected sample data: dominated by currently registered donors Internet survey 6. Summary: Emerging TrendsB. Compensated Living Donation

22. Individual level data Detailed Cost-Benefit analysis Internet based survey Renal practitioners survey Policy recommendations 7. Further Steps