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Diana Chang Blanc shares this very interesting summary on the role that incentives play in improving immunization coverage and how, in fact, it proves to be more cost-effective in the final analysis. Many many thanks to her. Both the authors (Abhijit Banerjee and Esther Duflo) are Professors of Economics at the MIT. Duflo was recognized as one of the best eight young economists by the Economist magazine, and one of the hundred most influential thinkers by Foreign Policy. They recently brought out a book titled "Poor Economics: A Radical Rethinking of the Way to Fight Global Poverty". I saw its copies in "new arrivals" corner of bookstores when I was in New York recently. This article is an summary of a part of the same book. In short, the authors conducted an experiment with different ways of trying to improve immunization coverage in rural areas of Udaipur (Rajasthan State, India) through a randomized trial in collaboration with a local NGO. The concerned villages were divided into three groups, i.e. (a) control villages (no intervention); (b) those which were provided with reliable immunization service only; and (c) those which were provided with reliable immunization service PLUS "incentives" (in this case 1 kg bag of lentils costing just under a dollar for each immunization). After the experiment, the percentage of fully immunized children measured in these different categories of villages was (a) 6%; (b) 18%; and (c) 39%. This itself may not be of much surprise. However, the author also measured the cost of immunization per child and concluded that the intervention with "incentive" actually reduced the cost of immunization service delivery as follows. "Perhaps somewhat counter-intuitively, incentives actually reduced the cost per child immunized. Because incentives increased attendance three-fold over reliable service alone, the nurses that went to the village to immunize the children were kept busy. As a result, the costs of full immunization per child were halved. In the reliable service only group, it costs about $56 per child immunized compared to $28 per child immunized in the reliable service plus incentives group." "What is surprising is not that incentives work—this much we knew already from evaluations of PROGRESA and other CCTs in Latin America—but that very small, non-cash incentives can have such a large impacts on the take up of crucial such as immunization." The authors provide the following analyses/explanation to different performance of the approaches tried. The key words/concept are "procrastination", "action does not always follow attention", and absence of the things in poor people's life that non-poor people take for granted. The following are excerpts from the concerned part of the article. "..... active distrust of immunization (fear of the evil eye, for example) is not the key issue, at least for a vast majority of parents: in villages where no incentive was provided, the rates of immunization were high for the first two shots: 78% of them got one shot, for example. It is after the third immunization that rates dropped off. Perhaps parents were disappointed because their child did not seem to be appreciably healthier after the first two shots." "Or perhaps, they ran out of the will to get it done. This is our third lesson: procrastination seems to seriously get in the way, especially after a few shots. It is as if parents no longer had the will to stay the course, and convinced themselves, month after month, that if they missed this month they could always come back. This is where the lentils helped: by providing a reason to act today, rather than to wait till next month, they convinced a substantial share of parents to stick to the plan." "Even when governments or NGO’s are convinced that increasing the demand for immunization is important, they generally believe that this should be done through better information, and not incentives. The mistrust of incentives for immunization seems to come down to an article of faith for both those on the right and the left of the mainstream political spectrum: Don’t try to bribe people to do things that you think they ought to do. For the right, this is because it will be wasted; for the conventional left, which includes much of the public health community, this is because it degrades both what is given and the person who gets it. Instead, we should focus on trying to convince the poor of the benefits of immunization." "We think that both of these views are somewhat wrongheaded ways to think about this and other similar problems, for two reasons. First, our experiments demonstrate that, in Udaipur at least, while the poor might appear to believe in all kinds of things, there is not much conviction behind many of those beliefs: otherwise they would not change their mind so easily. Second, action does not always follow attention. Even if people were convinced of the value of immunization, children would not necessarily be immunized. This tendency to procrastinate is of course not unique to poor people. But the big difference is how little help they are getting to make the right choices." "We would like to borrow the conclusion of this article from the conclusion of the chapter on health in our book: “In rich countries, we are constantly helped to make the right decisions: We have no choice but to get our children immunized—public schools will not take them if they aren’t—and even if we somehow manage to fail, our children will probably be safe because everyone else is immunized. Our health insurers reward us for joining the gym, because they are concerned that we will not do it otherwise. Furthermore, we can take a number of things for granted: water comes ready to drink from our taps, we don’t need to sleep under a bed net because there is no malaria, etc. And perhaps most important, most of us do not have to worry where our next meal will come from. In other words, we rarely need to draw upon our limited endowment of self-control and decisiveness, while the poor are constantly being required to do so. " "We should recognize that no one is wise, patient, or knowledgeable enough to be fully responsible for making the right decisions for their own health. The primary goal of health-care policy in poor countries should be to make it as easy as possible for the poor to obtain preventive care. This includes free services, but also everything we can think of to make things easier.” 11-06-Why-so-many-poor-children-miss-out-on-immunization.pdf

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