It’s time to start using cash incentives to boost vaccine take-up

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Roula Khalaf, Editor of the FT, selects her favourite stories in this weekly newsletter.

The writer is director of the centre for experimental social sciences at Nuffield College, Oxford. Professor Philip Clarke, who is at the Nuffield Department of Population Health, also contributed.

The international community spent more than $20bn supporting Covid-19 vaccination campaigns in low- and middle-income countries. It was one of the costliest public health initiatives ever targeted at these nations. Despite this, Africa trailed behind the rest of the world in terms of vaccination rates: a more equitable global pattern of jabs would have prevented the loss of hundreds of thousands of lives. And incentivising vaccination with cash would have saved many of them.

One of the many challenges Africa faced during the pandemic was simply getting average citizens, who recognised the important health benefits, to get vaccinated. Evidence from higher income countries indicated that financial incentives could motivate Covid vaccination rates. And some policymakers, such as Rabah Arezki, the Chief Economist of the African Development Bank Group, advocated for such incentives as an ingredient in the rollout.

We can now demonstrate that this would have made a difference. In February 2022, we conducted a randomised trial in rural Ghana that confirmed that tailored cash incentives bolster the take-up of Covid vaccines. The effect was not just significant, it was large: the verified vaccination rate of those receiving a $3 payment was 9 per cent higher than those in the control group receiving no cash.

Our findings underscore the potential impact of cash on public health and on healthcare infrastructure in many countries, including those in Africa, already overburdened before a crisis hits. Responding to a global health shock, such as a pandemic, further undermines medical care and in many cases exacerbates health inequalities. Our data suggest that financial incentives can increase the rate of vaccinations — reducing the time and effort staff need to commit to a campaign.

But simply giving cash to some of the poorest individuals in the world, even ignoring the public health benefits, would have positive outcomes. In our trial the effective $3 cash incentive represented about 15 per cent of weekly food expenditures. Scaled up to national levels this would have represented an important economic boost during a severe negative economic shock. In Ghana, for example, a $3 financial incentive would have injected $70mn directly into the hands of consumers if vaccination rates reached the goal of 70 per cent.

The challenge is getting relatively small amounts of cash directly into the hands of those complying with health policies such as vaccination campaigns. Technology is making it easier to design such programmes, even in the most challenging contexts. In rural Afghanistan “virtual” cash is being delivered into the hands of poor women. The tech makes delivery efficient and less prone to corruption — significantly increasing the efficacy of vaccination campaigns.

Some will ask whether paying people to adopt good health behaviours is a desirable route to take. This is an important concern: supplementing social norms with cash could erode the public’s commitment to complying with important health campaigns. Our Ghana trial explored the effect of the scheme on individuals who did not receive cash for vaccines. Consistent with another recent trial in Sweden, our results showed no negative effect on vaccination levels. But this deserves further study.

The wake of the pandemic is a good time to reflect on how to best navigate global public health challenges when they arise in future. It’s important to recognise that vaccination limits are governed by the number of people willing to come forward. In ongoing vaccination campaigns, giving individuals in low- and middle-income countries small cash incentives to promote uptake could be a game-changer.