Is paying people to look after their health money well spent?

Many countries increasingly use cash incentives to encourage disadvantaged people to look after their health, but is this money well spent, or just a temporary fix? Two experts debate the issue on BMJ.com today.

Conditional cash payments to disadvantaged people to take care of their health have the potential to improve population health, reduce health inequality and save the taxpayer money, writes Richard Cookson from the University of York.

Over the past decade, behavioural conditions attached to receipt of state funded welfare, such as ensuring that people receiving unemployment benefit are actively seeking work or attending health check-ups, have become increasingly common. For example, US Medicaid focuses on screening and chronic disease and Solidario in Chile focuses on maternal and child healthcare.

Unhealthy behaviours impose huge costs on society as well as harming the individual, says Cookson, and are particularly common among disadvantaged people who are less responsive to health promotion messages such as taking folic acid before pregnancy, and less likely to take up free public health services such as screening and child health programmes.

Evidence is growing, he says, that well designed conditional cash transfer programmes are effective in increasing the use of preventive services and can improve health status, although more research is needed on cost effectiveness.

According to Cookson, disadvantaged people are more responsive to cash incentives and can be easily identified through the benefit system. This is not the nanny state "gone mad" or "excessive paternalism" it is "only fair that welfare recipients make simple changes in their behaviour to avoid burdening their fellow citizens", he concludes.

But Jennie Popay from Lancaster University, argues that such payments separate people off from society, labelling them as irresponsible and unwilling to behave in ways "defined as appropriate by people with little understanding of how to survive poverty."

According to Popay the evidence for these programmes is limited and the results mixed. Overall, she says, the programmes are stigmatising, difficult to target, administratively costly, and although they seem successful in changing simple behaviours such as uptake of services, they do not have a lasting impact on complex behaviours such as smoking and diet.

In addition, she says, research shows that far from being simple as Cookson argues, unhealthy behaviours are coping mechanisms that help people survive poverty and its "multiple humiliations".

"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", Popay warns.

In an accompanying feature, Karen McColl examines how New York City is taking a pioneering approach to public health by introducing a programme of conditional cash transfers to break the poverty cycle. 'Opportunity NYC' gives cash rewards to families for investing in their own health, education and welfare.

Source: BMJ-British Medical Journal