When Egon Jonsson was thinking about how best to support alcohol-addicted pregnant women, he thought of a controversial solution: paying them not to drink. The idea was inspired by studies that have offered shopping vouchers to pregnant women who succeed in giving up cigarettes.
But when Jonsson and his team at the Institute of Health Economics in Edmonton submitted a grant to conduct the study, the Canadian funders disagreed with the approach of providing shopping cards. “It’s about how it looks to the general public, that you pay something for somebody to abstain from alcohol use during pregnancy,” says Jonsson.
The funders did accept, however, that women who stay sober be paid in phone minutes, as the incentive wouldn’t likely be associated with cash by the general public, Jonsson explains. The trial will start this spring.
In the US and UK, the last decade has seen a growth in incentive schemes where health care providers pay people cash or retail vouchers to change unhealthy behaviours. These programs have been used to encourage patients to take medications regularly, get mammograms, and lose weight, for example. In lower income countries, conditional cash transfers have increased school enrollment and the uptake of preventive health services.
We contacted several experts to see if similar programs exist in Canada, but could not find any examples outside of Jonsson’s study. (There are, however, employer-led programs to reward healthy behaviours as well as public contests that offer prize draw entries to people who quit smoking.)
Vivek Goel, professor of public health and vice president of research at the University of Toronto, thinks financial incentives are more acceptable to Americans than Canadians because financial transactions at the doctor’s office are expected in the US. Goel further speculates that because the UK is “more of a class-based society” the idea that some people need extra financial help to take care of their health is less off-putting. (Incentives are by no means embraced across the board in these countries, however.)
One former civil servant in Ontario explained that health officials shy away from financial incentives because they are too closely aligned with private sector economics. “We’re obsessed with protecting the values of our public health system … we don’t get to flesh out really innovative ideas that might trigger different behaviours,” she said.
Incentive schemes tried in the US and UK have worked very well and appear to be affordable. So should Canadian funders and policymakers get over their reservations and start paying people to be healthier?
The evidence: incentives work, but in limited contexts
The evidence in support of paying people to improve their health is preliminary but promising. A systematic review published last year examined 10 studies that provided financial incentives to encourage smoking cessation and five that used incentives to encourage screening or vaccination. For smoking, 20% of those in the incentive groups quit smoking, compared with 8% in the control groups. For screenings and vaccinations, 58% of those who received cash and/or vouchers attended the appointments, compared with 45% in the control groups.
When an incentive program ends, however, the evidence is mixed as to whether people continue the healthy behaviour. The authors of a recent review concluded that incentives are most effective in altering “simple, discrete and time limited” health behaviours, like attending a doctor’s appointment or taking short-term medication.
Pregnancy may therefore be a good time to try incentives as pregnant women can reduce the risk of harm to their babies by quitting smoking or drinking alcohol for a relatively short period. In a study published earlier this year, when pregnant women were offered conventional treatments to quit smoking plus shopping vouchers worth approximately $750, 23% had stopped smoking when assessed near the end of their pregnancies. In comparison, among those who just received conventional treatment – counselling and/or nicotine replacement therapy – only 9% weren’t smoking at the end of their pregnancies. Another review of smoking during pregnancy found incentives were more effective than any other intervention tried.
In addition to being more successful in changing some behaviours compared to others, incentives also work better for certain people, says Theresa Marteau, the director of the behaviour and health research unit at the University of Cambridge. “Where there is most evidence for effectiveness for incentives is in those who tend to be poor, and have mental health problems … including addiction,” she says. A short term financial reward can help individuals overcome short-term cravings or other barriers that stand in the way of healthy behaviours, like going for a preventative health care appointment.
And for low-income populations, “the incentive amount represents a greater percentage of income and is more likely to be effective,” explains David Meads, a lecturer at the Leeds Institute of Health Sciences who is currently researching health incentive designs. “One of the main reasons for using incentives is reducing health inequalities,” he adds.
When simple, short-term behaviours are incentivized among low-income people with addiction, the results can be extraordinary. In a randomized study of injection drug users, people in one group were given a $120/person incentive, spread over six months, for getting all three doses of a hepatitis B vaccine. An outreach worker encouraged people in the other group to get the immunizations. In the incentive group, 69% received all three doses of the vaccine, compared with only 23% in the other group.
Successful financial incentive programs can also be more cost-effective than other interventions. In the study described above, the total costs were $220/person for those given incentives and $590/person for those assigned to an outreach worker. Other analyses have also found incentive schemes can be very cost-effective, given that they offset high health care costs associated with diseases such as lung cancer.
Arguments against paying patients to be healthier
There are several ethical and practical arguments against using financial incentives to change patient behaviour. George Szmukler, professor of psychiatry and society at King’s College London, argues the value of personal health “is corrupted or degraded by treating it as being on the same metric as money.” Plus, he adds, “if you become known as a person who needs to be paid to look after your health, that can be rather stigmatizing.”
Marteau disagrees with the corruption argument, pointing out that income and wealth are already major determinants of health. In England, 40% of women in routine and manual occupations smoke before or during pregnancy. Given the stigma associated with smoking, effective incentive programs can actually reduce stigma, she argues. The corruption and stigma arguments, she says, are “put forward by those with resources in this world,” she says, “not by those to who the incentives are being offered.”
Another common argument against financial incentives is that individuals might be more motivated to engage in a behaviour in the long run if they are never given a cash incentive. The “crowding out” phenomenon has been demonstrated in different contexts. In one of the most-cited examples, children who received an incentive to draw ended up drawing less after the incentive period than those who never received an incentive. But Marteau says crowding out only applies when you pay people to do something they are already doing. In a study reviewing numerous health incentive schemes, Marteau and a colleague found no evidence that unhealthy behaviors increased after the incentive was withdrawn.
If, however, a person thinks they will receive an incentive for stopping an unhealthy behavior, they may engage in that unhealthy behaviour to be enrolled in the program, Szmukler points out. “If it’s known that you get payment if you don’t take the medication, why would anyone say they want to take the medication?” Szmukler asks.
The most vociferous debate centres around paying people to take medication, especially drugs used to treat mental health disorders. Some worry patients will continue to take drugs, even if they find they have harmful side effects, because they are getting paid to do so. Joanna Pawelkiewicz, who advocates for safe and affordable housing for people with mental health needs, argues “it should be up to each person to decide what [interventions] work for them” and that health advocates should work on removing the barriers to those identified interventions. “One of the most effective interventions for my own mental health has been exercise but what if I can’t afford a gym membership?” she asks.
Lawrence Brown, a professor of health policy and management at Columbia University, is concerned that easy-to-implement incentive schemes can replace more difficult and long-term responses like changes to the built environment.
Emily Nicholas, a spokesperson with Patients Canada, disagrees with an either/or approach when it comes to incentives. “Maybe people need that [financial] kickstart but sustainability is the end goal, so alongside incentives we need to look at other long term solutions.”