Can incentives help accelerate disease elimination?

Incentives can be like magic- casting a spell on someone with incentives to drive certain behaviour. Understanding a community’s cultural context and leveraging what its members desire based on fulfilling a specific condition can be a powerful tool. However, can they be applied to accelerate disease elimination? The tool of incentives must be used meticulously in order to achieve improved outcomes and prevent harmful effects.

What are incentives?

WHO defines incentives as “all the rewards and punishments that providers face as a consequence of the organizations in which they work, the institutions under which they operate and the specific interventions they provide”.

Incentives have commonly been used in the past in smallpox eradication initiatives and continue to be used in elimination efforts for polio, malaria, and Neglected Tropical Diseases (NTDs). In addition, they are widely used across the broader health sector for community health workers, healthcare workers in hospital settings, and in development sectors such as Water, Sanitation, and Hygiene (WASH), food and agriculture, and education.

Where have incentives been successful?

Out of the sea of monetary and non-monetary incentives that exist, one of the types of incentives that have been successfully implemented were those where the incentive achieved was based on specific pre-determined progress- whether that was an individual or group-based improvement. We see this implemented in a Results Based Financing (RBF) program for education in Chile for instance, where a nationwide RBF-incentive program was implemented. Schools competed for a fixed amount of money to be distributed among teachers in proportion to their workload, and awards were given based on an indicator that included students’ test scores, retention rates, and other performance measures. A study assessing this program’s impact found that after two years, test scores for students in the fourth, eighth, and 10th grades increased between 0.16 standard deviations and 0.24 standard deviations for math, and 0.14 standard deviations and 0.26 standard deviations for language, as compared to the control group without the RBF scheme.

In the health sector, RBF was designed to increase maternal and child health services in Cameroon by paying health facilities bonuses based on the quantity and quality of services delivered. The program was implemented in 14 districts of the country. In this example, RBF served to increase providers and supplies available health facilities, although it did not increase the completeness of service provision during antenatal care and child health consultations.

While RBF is a great incentive to reward a measured progress, it’s always wise to give an individual person or organisation a range of incentives instead of one. If money isn’t a priority in a particular context, other incentives such as materials or food can be given as a reward for progress. This type of incentive was successfully implemented in the WASH initiative of the ‘Food-for-Work (FFW) project’ in Niger for a drought reduction program where the incentive of food was provided for building irrigation ditches.

Influencing outcomes

In the discussion of incentives, the difficult truth is that there is no perfect strategy to address concerns using incentives. If it’s an incentive that serves to be effective, it doesn’t necessarily have be sustainable. Once the desired outcome is achieved, there is no longer a need for the incentive. On the other hand, if an incentive does intend to serve for a longer term, it can have negative effects, such as potentially creating a culture of expectation around incentives in return for certain actions or desired behaviours. This can create mistrust between the community and governments, as there may be the perception that there is a hidden agenda behind the government’s agenda if they are paying people in order to achieve their objectives. Incentives can take away from the moral good will of doing something, and instead make it all about money. Finally, health equity is another concern for if the incentives put in place are only used by middle and higher-income classes of society, people in lower-income levels will not benefit from the health outcomes associated with the incentives, thereby furthering the cycle of health inequalities and poverty.

The sustainability of incentives

GLIDE, together with partners, is exploring ways in which health incentives can be used to accelerate disease elimination targets.  One possible recommendation in which sustainability of incentives can be addressed is by linking disease elimination programs in resource-poor settings to high-earning companies as part of a corporate social responsibility (CSR) initiative, which would then fund these incentives programs for a given number of years. However, disease elimination programs can run for close to ten years at times, so such a partnership would need to ensure financial sustainability for the duration of the initiative. Creating a partnership opportunity between the disease elimination program and several companies could ensure the incentives initiative is funded for the entirety of the disease elimination program.

The question of local capacity also arises, as though there are benefits in working with external partners, often countries lack the resources – financial, technical, and human – to continue and manage such programs on their own. Abrupt exits from funders and partners can lead to demotivation for the country actors involved in disease elimination initiatives, thus inhibiting progress. Ensuring the sustainability of such programmes also entails a handover and transition plan when an exit occurs, as well as training and capacity building of local stakeholders as a part of broader health system strengthening.

Engaging all actors – from communities and faith-based leaders to local and national government officials – in the design, implementation, and monitoring of incentives programmes can help build community investment in the success of such initiatives. Making disease elimination achievements everyone’s achievements would increase ownership and responsibility, and increase retention of the donors, program managers, and community health workers.

As a final observation, incentives have the potential to help accelerate disease elimination goals, but the design and delivery of such initiatives must consider long-term sustainability, local capacity building, and include a transition plan for the continued successful implementation of such programs when external funders and partners end their involvement. GLIDE and the University of California, San Francisco (UCSF) have undertaken a research study to explore how incentives can be used for disease elimination, and we encourage you to stay tuned for more.

References:

• World Health Organization, 2000
• Incentives and Accountability in Education: A Review, 2014
• Looking into the Performance-Based Financing Black Box, Evidence from an Impact Evaluation in the Health Sector in Cameroon, Policy Research Working Paper, 2017
• An Incentive-Based Beneficiary Compensation Scheme for the Construction of Rural Water and Sanitation Systems in East Timor
• Free images sourced from istockphoto.com