Friday, December 12, 2008

Vaccines: Careful What You Pay For

Paying poor countries to vaccinate kids sounds like a good idea—as long as no one games the system. A new study from the Institute for Health Metrics Evaluation in Seattle shows that dozens of countries exaggerated their vaccination statistics in order to benefit from financial incentives. As the Seattle Times points out, the Gates Foundation paid for both the vaccine incentive program and the study that criticized it.

The larger issue: what role should financial incentives play in health care? The IHME study, which was published in the Lancet, is not the final word on this debate.

The idea that financial incentives can backfire is nothing new—look at the U.S. tax code for multiple examples. Or the Israeli day-care study by Gneezy and Rustichini (instituting a fine on parents who were late in picking up their kids at daycare resulted in an increase, not a decrease, of late arrivals). You have to pay close attention to how these deals are set up. See the cash transfer programs Julio Frenk championed in Mexico for examples of how to do things right.

Here’s a question for anyone who wants to dig deeper into the IHME study: the program was aimed at kids who wouldn't otherwise have gotten vaccinated. So, did more kids get vaccinated, despite the exaggeration, than would have otherwise? Did their health improve? And if so, is it okay to tolerate a little distortion? How much distortion--5 percentage points or 10, or in this case 16 (74% actual rate vs. 90% reported rate)? On the other hand, if you can't trust the numbers . . .

Update: See Ruth Levine's post at Global Health Policy for a more in-depth analysis of the IHME study.

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