Over the past few decades, there has been increasing interest in using material economic incentives to change health behaviors among the world’s poorest and most marginalized populations. We’ve seen the rise of conditional cash transfers (CCTs) as the “silver bullet” in public health and poverty alleviation, with over 30 countries worldwide adopting some form of CCT strategy for education and health. CCTs, which provide cash payments to poor households or individuals contingent upon the completion of certain behaviors (e.g., school and health clinic attendance) or achievement of pre-specified outcomes (e.g., STI status), have been used to address everything from basic preventive care for children, to incentivizing in-facility labor and delivery, to encouraging safe sex practice for HIV and STI prevention. At the same time, the field of contingency management, which began as a way to positively reinforce abstinence among drug addicts, has evolved to target medication compliance for TB treatment and antiretroviral therapy (ART). Health innovators have been eager to pilot new approaches that employ monetary or material incentives to further their public health goals.
Within the CHMI database, there are a few hallmark examples of how material incentives are being used to: (1) change health behaviors at the individual level, (2) directly stimulate demand for services among the target user population, (3) indirectly stimulate demand by incentivizing staff to enroll more beneficiaries or refer patients to additional services. Some programs reward participants with cash, whereas others utilize subsidies, lotteries, prizes, and gift cards. Incentives are also combined in some instances with promotion of social capital, community education activities, mHealth, and innovative health technologies. Below are some examples of these kinds of programs profiled in the CHMI database:
INDIA – Directly stimulate demand for services; Referral Incentives
Janani Suraksha Yojana (JSY), which means “Safe Motherhood Scheme,” is a government-run CCT program that aims to reduce maternal and infant mortality by incentivizing antenatal care and institutional deliveries, particularly targeting families below the poverty line (BPL). This traditional CCT embodies the notion that providing cash incentives will help remove economic barriers to seeking reproductive care, stimulate demand for healthy behavior, and help interrupt the vicious intergenerational cycle of poverty and poor heath outcomes. Expectant mothers can receive between Rs 600-1,400 (USD $13-31) for having three antenatal care visits and delivering their baby in either a public hospital or private accredited facility. The program operates across 10 states: Uttar Pradesh, Uttaranchal, Madhya Pradesh, Chhattisgarh, Rajasthan, Bihar, Jharkhand and Orissa, Assam, and Jammu & Kashmir in both urban and rural areas. Families are eligible for monetary incentives for up to two live births, after which the mother or father can choose to adopt a permanent form of contraception for additional compensation. Rewards are also given to private providers that refer complicated births to accredited facilities for emergency cesarean sections. An initial evaluation showed modest impacts on maternal mortality, and a more recent report has shown that, in the first five years of implementation, institutional deliveries rose from 20% to 49%, with some higher increases in select states.
INDIA – Promote health behavior change; Organizational rewards for enrollment
Prerna is another Indian CCT program launched in 2010 under the Jansankhya Sthirata Kosh (Population Stabilization Fund). Prerna uses monetary incentives encourage girls to delay age of marriage and promote birth spacing, both of which are associated with healthier outcomes for mother and infant. Marriage before the legal age of 18 and adolescent pregnancy are particularly prevalent among poor girls with low educational attainment, especially those in rural regions. Therefore, this program targets this vulnerable group with cash incentives. Eligible couples can receive a monetary award ranging between Rs.10000 and Rs.19000, depending on the sex and number of children. Couples are identified by local NGOs and community organizations, which process the paperwork for verification by the government. To further shift local norms, the program presents couples with their checks at public award ceremonies with press coverage and accompanying messages about maternal and child health.
The program is active in the following states: Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan, Jharkhand, Odisha, and Rajasthan.
INDIA – Directly stimulate demand for services
The Smart Card Initiative in Karnataka, India was launched in 2004 and sought to bring a sense of inclusion and self-worth to sex workers, while motivating better health care practices among them. As part of this program, sex workers were being rewarded with incentives in the form of a "smart card" enabling them to accumulate points to be redeemed for discounts or gifts. The only condition for keeping the card valid is that the cardholder must report at least once every 3 months to a clinic set up by the Karnataka Health Promotion Trust (KHPT), to undergo a thorough health check-up for any symptoms of sexually transmitted infections (STIs) such as HIV/AIDS. Developed by KHPT in association with Ashodaya Mahila Samanwaya Samithi (AMSS) - an organization of sex workers from Mysore and Mandya districts - and with funding from the Bill and Melinda Gates Foundation's India AIDS Initiative, the pilot project initially involved 500 sex workers. Continuous effort on part of Ashodaya and others ensured that KHPT reached about 1400 female and 200 male sex workers active in Mysore city. The program is no longer active.
PAKISTAN & NICARAGUA – Promote Health Behavior Change
Treatment for tuberculosis is long, complicated, and can cause uncomfortable side-effects. As a result, roughly 40% of patients worldwide do not complete the full course of treatment. Such non-compliance is in part responsible for the nearly two million annual TB deaths and the rapidly emerging problem of drug-resistant bacteria. The current standard for encouraging medication compliance of Directly Observed Therapy (DOTS) requires health workers or other designated individuals to watch patients take their medication, a challenge in places with minimal human resources for health. This new strategy uses high-tech urine test strips and mobile phone SMS texts to remotely monitor patient adherence and rewards them with mobile minutes. This program demonstrates how new technologies, mHealth, and incentives can be used in combination to promote health behavior change.
CAMBODIA – Referral Incentives
The main purpose of the Private Public Mix is to form a more interconnected network of public and private providers, improving quality, cost and accessibility of health services by establishing better linkages across sectors. A sub-component of this program includes an incentive to encourage private providers to refer severe malaria cases to public health facilities. The incentive mechanism is a monthly lottery in which participants can receive prizes such as audiotapes, watches, fans, and various other prizes ranging from USD $20 to $30.
Beyond these programs, there were two examples of how incentives were directed at staff members to increase enrollment in existing programs. The Guimaras Health Insurance Project in the Philippines included an aggressive house-to-house campaign to increase enrollment, providing monetary rewards to the recruiters based on how many households they enrolled. Similarly, the KICH-Key Improvements in Community Health pilot program in Vietnam sought to reach higher coverage through their public health insurance options and incentivized the Vietnam Social Security Administration (VSS) to identify and enroll unreached members of the eligible population in the national social health insurance scheme. These expansion incentives work through intermediaries, such as recruiters and promoters, to stimulate demand among the target population. There was also one example of a supply-side incentive, in which providers of health services are the target group for the monetary reward. The Blindness Prevention Program in South Africa not only provided training to public sector surgeons in how to remove cataracts safely and successfully, but also rewarded them with “performance payments” for reaching a pre-determined target number of procedures.
These examples, while not expansive, showcase the diverse ways in which material economic incentives can be applied to address a range of public health issues by targeting various actors, from providers to patients, particularly in ways that involve both the public and private health sectors. Material rewards can be a powerful approach to increase utilization of services and ultimately improve health outcomes, especially when used in combination with other interventions targeting quality improvement, operational efficiency, education, and community engagement. Though incentives are not a perfect strategy, as more evidence is generated about the effectiveness, efficiency, and optimal design of such programs, there will be even greater opportunity to apply incentive mechanisms in novel ways to improve health and decrease disparities among the world’s poorest and most marginalized populations.
Photo: A voucher scheme in Cambodia aims to increase use of reproductive health services in rural communities. Photo by Arjun Vasan for CHMI.