Published 8 July 2008, doi:10.1136/bmj.a594
Cite this as: BMJ 2008;337:a594

Head to Head

Should disadvantaged people be paid to take care of their health? No

¹ Lancaster University, Lancaster LA1 4YW

Feature, doi: 10.1136/bmj.a673

Many countries are turning to cash incentives to encourage people to look after their health. Richard Cookson (doi: 10.1136/bmj.a589) argues that such schemes can save money in the long run, but Jennie Popay believes the problems need a deeper solution

Of course people living on low incomes would welcome more cash, but handouts conditional on behaving in ways defined as good by highly paid health professionals are highly problematic.

So what is the problem? Poverty has long preoccupied public health, and social reforms and charitable handouts have always been part of the response. But the welfare systems introduced in countries in the Organisation for Economic Cooperation and Development in the early 20th century signalled a shift from "the poverty problem" to a concern with inequality: from charity to comprehensive systems of social protection based on entitlement.¹ These systems were not perfect but their fundamental aim—to develop fairer, more inclusive and cohesive societies—remains relevant.²

Labelling poor people

Increasingly, however, conditional cash transfers are the acceptable face of contemporary global welfare.³ Like means tested benefits, these transfers are stigmatising, separating off poor people from society. But they are doubly stigmatising because they also mark people out as irresponsible, unwilling to behave in socially acceptable ways. Unlike benefits that require people to meet predefined eligibility criteria (such as caring for dependent children or having income below a certain level) they also make the transfer of cash, often needed to meet the most basic of needs, conditional on recipients adopting behaviours defined as appropriate by people with little understanding of how to survive in poverty. Cash transfers dependent on behavioural and financial conditions now target all aspects of poor people’s lives: US Medicaid focuses on screening and chronic disease management, Oportunidades in Mexico and Solidario in Chile focus on maternal and child healthcare, and initiatives in the UK focus on further education and employment.

But do they work? The evidence is limited, but the box shows some of the reported benefits and disbenefits.⁴ In summary, there are positive benefits but results are mixed, benefits generally small, and positive outcomes more likely for service use than for health status or behaviour change.

Benefits and drawbacks of conditional cash transfers4 Benefits Reduction of poverty; increased consumption of nutritious food Increased school registration and attendance Increased uptake of preventive services including maternal and child health Improved education and health outcomes (eg, decreased incidence of diarrhoeal disease) Reduced child labour Increase in health related knowledge Empowerment of women communities Reduced household asset depletion (eg, less likely to sell food to pay medical fees) Increased accumulation of assets (education, livestock, etc) Drawbacks Low coverage and poor specificity Limited attention to improving service access, quality, or outcomes Focus on human capital development rather than on sociocultural capital Perverse incentives (eg, increased fertility; low nutritional status of children maintained to ensure eligibility) Burden for women as primary carers Stigma Complexity leads to administrative problems: inefficiencies, high corruption risk and high transaction costs High compliance costs (eg, travelling long distances to use poor quality services)

Many of these problems are the same as those reported for decades in research on targeted means tested policies. These programmes are difficult to target, administratively costly, and they have little transformative potential at the individual or societal level. They are also doubly stigmatising. Given this, the key question is whether behavioural conditionality itselfhas any added value. A recent paper on Oportunidades in Mexico reports that gains in children’s health, growth, and development were directly and positively related to the level of cash transfer—the more cash people received the more children gained—albeit that some improvements were too small to be clinically meaningful.⁵

Conditions are unnecessary

So some behaviours are responsive to cash payments, but this does not mean that behavioural conditionality is necessary. Research on cash benefits for dependent children in South Africa that are not linked to behavioural conditions found mothers spent the money on food, clothing, and school fees.⁶ Similarly, an experimental study of cash benefits without behavioural conditions in rural Ecuador similarly reported positive outcomes for physical, cognitive, and socioemotional development of children, and the poorest children had outcomes 20% of a standard deviation higher than comparable children in the control group.⁷ And research in the UK has repeatedly found that poor mothers spend the unconditional universal child benefit on promoting and protecting their children’s health and wellbeing, often at risk to their own.⁸ When extra cash is available and people are able to make healthier choices, they often do so.

But some behaviours in low income groups are very resistant to change. In this context, the conclusions of a recent King’s Fund review are important.⁹ Although cash incentives seem to change simple behaviours (such as uptake of services), they fail to have lasting impacts on complex behaviours—that is, those closely linked to increased risk of serious ill health and premature mortality (smoking and diet). It is not too difficult to see why. These unhealthy behaviours may be "enjoyable," as the authors of the King’s Fund report suggest. But, more fundamentally, research shows they are woven into the fabric of poor people’s social lives, operating as coping mechanisms and helping them survive poverty and its multiple humiliations.¹⁰ To change such behaviours is neither simple nor low effort. Cash might coerce some people into changing behaviour but if their lives do not change we should not be surprised if they lapse or substitute other (perhaps equally) unhealthy behaviours.

William Beveridge’s report on social insurance after the first world war identified five giants on the "road to reconstruction": want, disease, ignorance, squalor, and idleness.¹¹ The response to Beveridge’s giants—universal systems for social security, health care, and education free at point of use and action to build and sustain full employment, increase public housing, and renew neighbourhoods—have delivered unprecedented improvements in living standards and population health.^{12 13} Surely, we can respond to the 21st century’s giants of inequality in income, wealth, and health with something more imaginative and a greater likelihood of success than meagre stigmatising conditional cash transfers supported by a fragile evidence base. Perhaps history is a better source of evidence for public health than economics when it comes to understanding what works to reduce poverty and health inequalities.

Cite this as: BMJ 2008;337:a594

Feature, doi: 10.1136/bmj.a673

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Competing interests: None declared.

References

1. Townsend P. The right to social security and national development: lessons from OECD experience for low income countries. Issues in social protection discussion paper 18. Geneva: International Labour Office, 2007.
2. Jones K. The making of social policy in Britain 1830-1990. 2nd ed. London: Athlone Press, 1994.
3. Shibuya K. Conditional cash transfer: a magic bullet for health? Lancet 2008;371:789-91.[CrossRef][Web of Science][Medline]
4. Popay J. Escorel S, Hernandez M, Johnson H, Mathieson J, Rispel L. Understanding and tackling social exclusion. Final report of the WHO social exclusion knowledge network. Geneva: WHO, 2008
5. Fernald LCH, Gertler PJ, Neufeld LM. Role of cash in conditional cash transfer programmes in child health, growth and development: an analysis of Mexico’s Oportunidades. Lancet 2008;371:828-37.[CrossRef][Web of Science][Medline]
6. Inter-Regional Inequality Facility. Social grants: South Africa. Policy brief 1. London: Overseas Development Institute, 2006.
7. Paxson C, Schady N. Does money matter? The effects of cash transfers on child health and development in rural Ecuador. World Bank policy research working paper 4226. Washington, DC: World Bank, 2007.
8. Strelitz J, Lister R, ed. Why money matters: family income, poverty and children’s lives. London: Save the Children, 2008.
9. Jochelson K. Paying the patient: improving health using financial incentives. King’s Fund, 2007. www.kingsfund.org.uk/publications/other_work_by_our_staff/paying_the.html.
10. Graham H. When life’s a drag: women, smoking and disadvantage. London: HMSO, 1993.
11. Beveridge W. Report of the inter-departmental committee on social insurance and allied services. London: HMSO, 1942. (Cmd 6404.)
12. Drever F, Whitehead M, eds. Health inequalities. London: Office for National Statistics, 1997.
13. Navarro V, Muntaner C, Borrell C, Benach J, Quiroga A, Rodriguez-Sanz M, et al. Politics and health outcomes. Lancet 2006;368:1033-7.[CrossRef][Web of Science][Medline]

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