Vaccine hesitancy, a global threat to public health, has picked up new steam in the Covid-19 era. In a recent World Economic Forum/Ipsos survey of almost 20,000 adults from 27 countries, 26% said that they wouldn’t get vaccinated against Covid-19. Over half of the non-vaccinators were worried about side effects, while the second most common reason cited for staying away from an eventual Covid-19 vaccine was doubt about its effectiveness. Covid-19 vaccine distrust was particularly high in Europe.
Skepticism about vaccines has spread to all part of the political spectrum. In the US, even some liberals who are normally pro-vaccine are nervous about the Trump administration pushing through an untested Covid-19 vaccine.
But vaccination will be essential to get the world back on its feet. In many countries certain vaccinations are mandatory, for instance for children to be enrolled in public education. But forcible vaccination isn’t universal or always effective.
Educating the public about the benefits of vaccines, and the misinformation that falsely links vaccination with autism and other issues, is necessary. But it’s also a painstaking, gradual process of listening to people, understanding their concerns, and building their trust in medical institutions. That’s important for the long term, but can be hard to achieve in the short term.
So one proposed short-term solution, in the face of this vaccine hesitancy, is to simply pay people to get the Covid-19 vaccine. Robert E. Litan, an economist at the Brookings think tank, has suggested this for the US. His proposal isn’t the product of rigorous economic analysis – he mentions a gut feeling that the right payment amount would be $1,000. This would work out very expensive to achieve an 80% coverage rate – $275 billion in total. This is the equivalent of half of Medicaid spending for a year, one critic has noted.
It might be especially difficult for poor countries to justify this expense. In an online press briefing on September 3, Mitoha Ondo’o Ayekaba, the Vice Minister of Health and Social Welfare for Equatorial Guinea, commented that “we might not even have the means to roll that out properly.” He noted that vaccine hesitancy is not yet a problem in Equatorial Guinea, Africa’s only Spanish-speaking country. And even if it does spread, he doesn’t think that cash transfers are the right approach.
But ultimately in the US, economist Litan believes, the benefits would make the expense worthwhile. There could even be a form of social persuasion baked into the model, where people are paid a smaller amount upfront (e.g. $200); they would receive the rest if enough other people agree to be vaccinated.
It’s an intriguing suggestion, which has some support. But it’s not an entirely novel one. For decades, health organizations in low- and middle-income countries have been paying people to get vaccinated (and adopt other health measures, such as visiting doctors for prenatal care). These conditional cash transfers (CCTs) often use very small amounts of cash or products. In a 2011 study in rural Kenya, for instance, mothers were sent 150 Kenyan shillings (approx. $2) via the mobile money platform M-Pesa for having their children vaccinated (against diphtheria, tetanus, whooping cough, hepatitis B and Haemophilus influenza type b) within 4 weeks of the target date. In a Pakistani study carried out between 2016 and 2017, the cash incentive ranged from $5 to $10.
These types of studies show mixed, but broadly positive, results. The Pakistani trial led to higher vaccination rates and more compliance with vaccination schedules. In Nicaragua a CCT program led to substantial increases in vaccination coverage, in some cases over 95%.
These programs can’t immediately be transposed for Covid-19. For one thing, CCT trials in international development have typically involved children, while the success of any Covid-19 vaccine would depend on adult take-up. And the initial scarcity that’s likely for the first Covid-19 vaccine may mean that there will be no need to pay people to take it (we might see the converse situation, of people overpaying amidst hiked prices). Plus, vaccine hesitancy is often a larger problem in wealthy countries, rather than the low- and middle-income countries where CCT trials have typically taken place.
But as a possible health policy tool, it’s useful to keep CCTs in the arsenal. Nobel Prize-winning economist Abhiit Banerjee noted in an online press briefing on September 9 that it’s unhelpful to insist that “we should never pay people to do what they should do on their own.” Payments for socially beneficial behaviors have their place.
When it comes to vaccination, no amount of money may be enough to convince die-hard antivaxxers, but a cash payment could be the needed nudge for people on the fence. As Banerjee pointed out, on-the-fencers make up a large proportion of vaccine-hesitant people. “A lot of people have mild uncertainties without really having a strong opposition,” he said. He described a randomized controlled trial he was involved with in India, where his team had been told that local residents had a deep-seated opposition to vaccines. Yet they found that this supposedly strong opposition went away quite easily. The trial participants were offered “one kilo of dry beans every time they got vaccinated and the vaccination rate went up by six times. So you know, I’m less convinced that everybody has strong ideological views. A lot of people just don’t do it because they don’t do it.”
“I think a small reward for getting vaccinated will get a bunch of people in,” Banerjee reflected. “And a bunch of people won’t, but that might still get us to the point where we have enough herd immunity.”