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In their randomised trial showing reduced in-hospital mortality after improved management of children under 5 years with malaria, Biai et al concede that “we cannot distinguish between the effect of supervising the implementation of the guidelines and the effect of the financial incentive in reducing mortality.”1 But this crucial point was lost in the abstract—and in others' interpretations:
There was no mention of how the unequal hospital environment created by the study may itself have contributed to the results. It would have been useful to hear from the nurses and doctors themselves. How did it feel to be in the control group, to receive no extra money, and to have to continue moonlighting to pay for food and rent, while colleagues (working in a similar children's ward in the same building) enjoyed a monthly bonus ($50 and $160 a month for nurses and doctors respectively)? The bonus is described by authors and commentators as small, but small is relative. We are not told the basic salaries of nurses and doctors in the study, but in Guinea-Bissau, where this study took place, a chief nurse with 18 years' service reports that she earns less than $100 a month.4
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Competing interests: None declared.