By Dr. Orin Levine and Amanda Glassman
In low- and middle-income countries, children living in poverty are less likely to be vaccinated -- and more likely to die or become ill from a vaccine-preventable disease -- than wealthier children.
A perfect example of this can be found in Nigeria, where less than 5 percent of children in the lowest quintile of the wealth distribution were fully vaccinated in 2003 -- as opposed to 40 percent of children in the wealthiest quintile. (For more on inequalities in health, see here.) Although a lack of effective supply and distribution systems limits the reach of immunizations -- especially to "last mile" populations -- much progress has been made and innovative strategies are underway to strengthen vaccine supply chains (see here for some examples).
However, as CGD's Charles Kenny noted last month in "Foreign Policy," few efforts focus on the "demand-side" -- the barriers that poor families face when considering whether or not to vaccinate their children. Yet according to recent impact evaluations, providing modest cash or in-kind incentives to poor families conditional on vaccination of their children has worked in at least five developing country settings. (See here and here.) Based on these positive evaluations, we believe that conditional transfer programs are a promising demand-side way to address vaccination coverage levels that should be tried and evaluated in multiple settings.
But will these schemes get the attention and evaluation they deserve? This depends in part on whether we can address the concerns of donors and policymakers who worry about the economics and ethics of cash and in-kind transfers for vaccination. Specifically, many worry that cash transfers for vaccination will diminish intrinsic motivations for getting children vaccinated and create long-term dependency on the transfer.
In our view, while legitimate questions to ask, these concerns are unfounded. Here's why:
Since families benefit from vaccination by avoiding vaccine-preventable morbidity and mortality, policymakers question why a government should provide additional cash or in-kind subsidies. Yet we know that poor families don't invest sufficiently in their children's health -- the inequalities in health status and coverage make this clear. Poor families don't have enough money to cover costs of seeking care, nor do they engage preventive services as much for a number of reasons (high discount rate, intangible benefits, risk perceptions etc.).
There are also other sociocultural barriers that make health services "unfriendly" to poor and vulnerable households in addition to misconceptions about the safety of vaccination. The conditional transfer intends to adjust this cost-benefit analysis for poor households by bringing the benefits of vaccination more tangibly and immediately into view and by reducing the cost associated with obtaining the vaccine. Finally, the benefits of vaccination do not accrue only to the individual or household; so providing "compensation" to the poorest for giving the benefit of herd immunity to others is also a good argument.
Some policymakers argue that paying people commoditizes people or behaviors, or that such a transfer can be considered a "bribe." While important to support intrinsic motivations, is the counterfactual situation ethical? Is it okay to leave some children unvaccinated because their parents are too poor or lack sufficient knowledge? An unvaccinated child is more likely to become ill and die from disease than a vaccinated child. If repeated evaluations show that an intervention can significantly increase vaccination coverage among the extreme poor, is it ethical to withhold this intervention? (HT Mead Over)
Building off the U.S. preoccupation with welfare dependency, policymakers also worry that poor families will become dependent on cash or in-kind transfers, and that transfers are not sustainable over the long-term. We consider this highly unlikely to occur because (i) the amount of the transfer is marginal with respect to a beneficiary household's consumption, so it is unlikely to create a permanent change in consumption patterns or affect employment choices; (ii) households automatically "age out" of the conditional transfer -- if a family does not have kids below the age of five, then they do not qualify for the transfer; (iii) conditional transfers can be thought of as transitional programs to "educate" poor households on the benefits of prevention.
In Nicaragua, a conditional cash transfer substantially increased vaccination and use of preventive services. Once the demand-side transfer was eliminated (for political reasons), however, utilization of preventive services on the supply side was maintained at almost the same level, suggesting that families had learned the value of preventive care, or had become comfortable using the services because of familiarity with them.
Up to one in every five children in the world doesn't yet get the life-saving vaccines they need. Even more remain needlessly vulnerable because they are delayed in receiving vaccines. Overcoming this challenge will likely require a broad set of policy tools. Unfortunately, we have few demand side tools at this time in our tool box. In our view, conditional transfers represent a promising approach that warrants further evaluation. Concerns about the ethics and economics of this approach seem to argue for, not against, investigating these programs further.