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Using financial incentives to achieve healthy behaviour

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1415 (Published 09 April 2009) Cite this as: BMJ 2009;338:b1415
  1. Theresa M Marteau, professor of health psychology1,
  2. Richard E Ashcroft, professor of bioethics2,
  3. Adam Oliver, RCUK senior academic fellow in health economics and policy3
  1. 1King’s College London, Guy’s Campus, London SE1 9RT
  2. 2School of Law, Queen Mary University of London, London E1 4NS
  3. 3LSE Health, London School of Economics and Political Science, London WC2A 2AE
  1. Correspondence to: T M Marteau theresa.marteau{at}kcl.ac.uk
  • Accepted 31 March 2009

Paying people to change their behaviour can work, at least in the short term. However, as Theresa Marteau, Richard Ashcroft, and Adam Oliver explain, there are many unanswered questions about this approach

Personal financial incentives are increasingly being used to motivate patients and general populations to change their behaviour, most often as part of schemes aimed at reducing rates of obesity, smoking, and other addictive behaviours (table⇓). Opinion on their use varies, with incentives being described both as “key to reducing smoking, alcohol and obesity rates” and as “a form of bribery” and “rewarding people for unhealthy behaviour.” We review evidence on the effectiveness of financial incentives in achieving health related behaviour change and examine the basis for moral and other concerns about their use.

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Examples of current incentive schemes aimed at changing health related behaviours

Do personal financial incentives work?

Financial incentives and disincentives inform the fiscal policies of all governments. Disincentives, in the form of tobacco and alcohol taxes, are known to affect behaviour,10 but the effect of positive financial incentives is less clear. In theory, they work on learning theory principles by providing an immediate reward for behaviours that usually provide health gains in the longer term.11 They also capitalise on “present bias,” a tendency for many of us to pursue smaller immediate rewards instead of rewards that are distant but more highly valued.12

Financial incentives form part of programmes in low and middle income countries aimed at breaking intergenerational cycles of poverty.13 Payments, known as conditional cash transfers, are made for using prevention services and achieving educational targets. Although these programmes improve health outcomes, uncertainties remain about the processes by which the payments work, their effect sizes, and cost effectiveness.14

In high income countries financial incentives have most often been used as part of programmes …

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