Published 8 July 2008, doi:10.1136/bmj.a589
Cite this as: BMJ 2008;337:a589

Head to Head

Should disadvantaged people be paid to take care of their health? Yes.

¹ Department of Social Policy and Social Work, University of York, York YO10 5DD

Feature, doi: 10.1136/bmj.a673

Many countries are turning to cash incentives to encourage people to look after their health. Richard Cookson argues that such schemes can save money in the long run, but Jennie Popay (doi: 10.1136/bmj.a594) believes the problems need a deeper solution

One reason the NHS costs so much is that people do not look after their health. Unhealthy behaviours impose huge costs on society as well as harming the individual. For example, the painful and costly outcome of tooth decay requiring reconstructive surgery in young children is preventable through simple actions by parents, such as supervising tooth brushing and limiting consumption of sugary drinks. Better access to free preventive dental care might help, but this is also a behavioural problem.

Unhealthy behaviours are particularly pervasive among disadvantaged people, who are less responsive to health promotion messages (such as take folic acid before pregnancy or read to your toddler) and less likely to take up free public health services (such as screening programmes). The causes are complex and structural—stressful material conditions and social environments leading to poor mental health and chaotic lifestyles rather than idleness or wantonness as was popularly thought in the 19th century.

There is therefore a case for paying disadvantaged people to take care of their health through a conditional cash transfer. It’s a bit like a tax on pollution or, rather, a subsidy for not polluting. It’s worth doing if the health benefits outweigh the costs. It may sometimes even save the taxpayer money, if the long term savings are substantial. Of course, we should always be wary of fairytale claims about long term savings. An ounce of prevention is not always worth a pound of cure. But sometimes it is.

The case for offering "prevention payments" to the general population is weak, because of the high costs of administration and waste in paying people for doing what they are already doing. The case for means tested prevention payments is stronger, because disadvantaged people are less likely to be doing prevention activities already, are more responsive to cash incentives, and can be identified through the benefit system. This would also help to tackle growing health inequalities between rich and poor. Arguably, it is also fair that welfare recipients should be expected to make simple low effort changes in their behaviour to avoid burdening their fellow citizens.

Evidence of effectiveness

This idea is part of the broader international shift in the last decade towards conditional cash transfers—that is, behavioural conditions for receipt of state funded welfare, such as the requirement for people receiving unemployment benefit actively to seek work. This shift has gone furthest in the developing world, with conditional cash transfer programmes requiring disadvantaged families to send children to school and to attend maternal and child health clinics. The first major programme was Progresa(now Oportunidades) in Mexico¹; programmes have since spread to other countries in Latin America (such as Brazil, Columbia, Hondurus, Nicaragua) and elsewhere (including Bangladesh, Jamaica, Malawi, Nepal).

A recent systematic review of controlled studies in developing countries found that "Overall, the evidence suggests that conditional cash transfer programmes are effective in increasing the use of preventive services and sometimes improving health status," although it warned that further research is needed on cost effectiveness.² Other reviews have come to similar conclusions.^{3 4 5} In 2007, New York City announced a pilot programme of conditional cash transfers for various activities to promote health.⁶ In the UK, a programme of educational maintenance allowances has been phased in since 2004, which pays young people from low income families to attend training and education after the age of 16.⁷ In February 2008, Prime Minister Gordon Brown mooted the idea of a broader conditional cash transfer programme, including cash incentives for children to attend health check-ups.⁸

Careful implementation

Carefully designed conditional cash transfers have the potential to improve population health and reduce health inequality. By averting the need for costly public expenditure, they may even reduce the tax burden.

Conditional cash transfers are not a panacea, however, and should not be used as ideologically driven political gimmicks. Programmes need careful piloting and evaluation of cost effectiveness in well designed studies with meaningful outcome measures—not just the descriptive case studies that all too often pass for evaluation of UK government programmes. They should be used only when the programme is likely to do more good than harm to disadvantaged individuals, taking account of compliance costs, stigma, and stress to recipients⁹; the behaviour change is sufficiently verifiable to deter fraud and gaming; and the programme is likely to be cost effective, taking account of all benefits and costs, including administration and monitoring.

Are conditional cash transfers an example of the nanny state gone mad? Not really. One person’s unhealthy behaviour imposes external costs on fellow citizens. So this is not excessive paternalism. It is partly an application of John Stuart Mill’s classic harm principle: "The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others." In this case, the harm is financial: unhealthy behaviours increase the tax burden. General practitioners already receive financial payments to do what the state thinks is best (through the quality and outcomes framework). If we pay general practitioners to comply with evidence based guidance, then why not pay less advantaged people as well?

Cite this as: BMJ 2008;337:a589

Feature, doi: 10.1136/bmj.a673

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Competing interests: RC is a member of the NICE public health interventions advisory committee.

References

1. Gertler P. Do conditional cash transfers improve child health? Evidence from Progresa’s control randomised experiment. Am Econ Rev 2004;94:336-41.[CrossRef][Web of Science]
2. Lagarde, M, Haines, A and Palma, N. Conditional cash transfers for improving uptake of health interventions in low and middle income countries: a systematic review. JAMA 2007;298:1900-10.[Abstract/Free Full Text]
3. Kane RL, Johnson PE, Town RJ, Butler M. Economic incentives for preventive care. Rockville, MD: Agency for Healthcare Research and Quality, August 2004. (Evidence report/technology assessment No 101.)
4. Lussier JP, Heil SH, Mongeon JA, Badger GJ, Higgins ST. A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction 2006;101:192-203.[CrossRef][Web of Science][Medline]
5. Rawlings LB, Rubio GM. Evaluating the impact of conditional cash transfer programs: lessons from Latin America. Washington, DC: World Bank 2003. http://papers.ssrn.com/sol3/papers.cfm?abstract_id=636482#PaperDownload.
6. Opportunity NYC. What is opportunity NYC? www.opportunitynyc.info.
7. Department for Employment and Learning. Education maintenance allowance FAQs. 2005. www.delni.gov.uk/index/further-and-higher-education/ema-educational-maintenance-allowance/ema-faqs.htm.
8. Webster P. Cash for families that beat poverty trap. Times 2008 Feb 15. www.timesonline.co.uk/tol/news/politics/article3372181.ece.
9. Fein DJ, Lee WS. The impacts of welfare reform on child maltreatment in Delaware. Children Youth Serv Rev 2003;25:83-111.[CrossRef]

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