Providing cash to promote healthy living: Does it work?

In conditional cash transfer (CCT) programs, individuals are offered a financial reward on the condition that they comply with certain behaviors, like receiving immunizations or enrolling their children in school. CCTs have been used to promote health-related behavior change including uptake of preventive health services. Advocates of CCT programs believe these programs serve two important purposes in poor communities. First, they reduce poverty in households by providing assistance in the form of money. Second, they prevent future generations of poor households from remaining poor because they increase human capital by promoting behaviors such as healthy living and greater school attendance. CCTs are viewed as a way of alleviating poverty and breaking the generational cycle of poverty by investing in human capital. 

CCTs are meant to level the playing field for low-income families.  The premise is that CCTs remove the financial barrier associated with receiving healthcare. For the poorest people living in developing countries, there are multiple costs associated with uptake of health services. There are direct costs of using health services (in many settings healthcare services are not free even for the poor, and a high percentage of the cost of healthcare services are paid for out of pocket at the point of care), indirect costs such as the cost of transportation to a facility, and opportunity costs in the form of lost income as a result of time spent away from work while accessing health services. Monetary transfers offset these three costs and increase the likelihood that individuals use health services. 

In addition to the costs associated with healthcare utilization, studies have shown that traditional cultural beliefs may negatively influence the use of healthcare services. In many cultures, disease is perceived as a natural part of the aging process; therefore, individuals do not seek medical care. Some turn to alternative and complementary treatments with unknown effectiveness. In some locations, cultural beliefs about the role of women in society result in lower rates of uptake of health services by women. CCTs may help increase health services utilization in these settings, especially in vulnerable populations such as women and children. 

One area where CCTs have been used to modify health behavior is safe sex practices. A study published in BMJ earlier this year, examined the effect of CCT programs on safe sex behaviors in rural Tanzania. A group of over 2,000 participants from 10 villages in Southwest Tanzania were randomly assigned to receive either high value CCT (greater financial reward), low value CCT (lesser financial reward), or no CCT. Cash transfers were given to participants in the CCT arms of the study if they tested negative for a sexually transmitted infection (STI) at the 4, 8, and 12 month period of the study. The authors found that the patients receiving the CCTs were at lower risk of testing positive for STIs as compared to participants who did not receive any CCTs. Another study last year from Brazil, examined the impact of CCTs offered by the Brazilian government on nutritional status of poor children. In this study, the medical records of more than 20,000 children under the age of five, who were living in poverty, were examined. The investigators found that anthropometric measurements of nutritional status, including height and weight were more likely to be normal in children whose families received CCTs. 

CCTs have been studied in the developed world to modify health behaviors as well. A study in 2009 found that General Electric employees who received cash for participating in a smoking cessation program or quitting smoking, were more likely to keep up smoking cessation or abstain from cigarettes. Similar studies in the area of obesity have also shown promise. Recognizing the potential for such rewards to promote healthy behavior, many companies are providing incentives for their employees by offering financial rewards to workers who adhere to healthier habits such as smoking abstinence or regular blood cholesterol checks. The rational is simple: if their employees are healthier, it will curb cost by reducing insurance premiums. 

While this reasoning seems to make sense, it still remains to be seen whether the long-term savings from such cash transfers will offset the short-term costs. Future studies that address this question could shed light on the lasting value of CCTs. Additionally, while many studies have shown modifications in health-related behavior in the short-term, more research examining long-term health outcomes in patients may help offer more conclusive evidence on the effectiveness of such programs and expand our knowledge of creative strategies for health behavior modification. 

References

Ranganathan M et al.  Promoting healthy behaviours and improving health outcomes in low and middle income countries: A review of the impact of conditional cash transfer programmes.  Preventive Medicine, (2012), doi:10.1016/ j.ypmed.2011.11.015

de Walque D, Dow WH, Nathan R, et al. Incentivising safe sex:
 A randomised trial of conditional cash transfers for HIV and sexually transmitted infection prevention in rural Tanzania. BMJ Open, 2012;2: e000747. doi:10.1136/ bmjopen-2011-000747

Paes-Sousa R, et al.  Effects of a conditional cash transfer programme on child nutrition in Brazil.  Bulletins of the World Health Organization, 2011 Jul 1;89(7):496-503.