The authors recount an absolutely fascinating series of experiments designed to get more people to immunise their children in rural Rajasthan. Again: hugely beneficial action, and thanks to the NGO they worked with, readily and freely and reliably available. But also something with a small cost—perhaps a couple of hours off work and the trudge to the clinic, and benefits that are intangible and lie in the future. Result: abysmal immunisation rates.
Their idea: a small bag of lentils given as a sort of “reward”. This was opposed by public health officials, who thought “bribing” people to do what they should do anyway was a bad way to go. Yet it had a dramatic effect—and actually reduced the cost per immunisation to the NGO, because the nurses who had to be paid for the whole day anyway were now busier. Yes, convincing people of the benefits is probably useful in the long run, but this does the trick much better and more quickly—and, possibly, experience with immunisation is a pretty valuable kind of "convincing". And yes, it's paternalistic. But a whole host of things are essentially done for us—often by a paternalistic state, which purifies our drinking water and provides sewage systems and so on. There are many, many areas where we simply do not have to take responsibility because stuff is done for us, or made incredibly easy. But the poor must actively decide to "do" them.
While there are huge rewards—probably the biggest uncollected rewards in health care—for getting the poor people of the world to consistently get vaccinated, etc., I wonder whether the idea of this experiment is applicable in the U.S. If you talk to doctors, one of their big complaints about health care is that their patients are insufficiently dedicated to the regime that the doctors have set up for them. This has particularly unfortunate results in the case of antibiotics, where a halfhearted application of the plan results in a resistant disease that’s just ready to add to the store of our future problems. People are pretty predictable procrastinators and such, and I wonder whether some sort of concrete, visible incentive might induce them to stick more faithfully to the plan. A rebate scheme seems like one potential idea.
Of course, to take advantage of this you need an incentive structure that prizes cost and care savings which gets back to the core payment issue in health care…but this is a subject for another time.