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Incentives, health promotion and equality

  • Kristin Voigt (a1)


The use of incentives to encourage individuals to adopt ‘healthier’ behaviours is an increasingly popular instrument in health policy. Much of the literature has been critical of ‘negative’ incentives, often due to concerns about equality; ‘positive’ incentives, however, have largely been welcomed as an instrument for the improvement of population health and possibly the reduction of health inequalities. The aim of this paper is to provide a more systematic assessment of the use of incentives from the perspective of equality. The paper begins with an overview of existing and proposed incentive schemes. I then suggest that the distinction between ‘positive’ and ‘negative’ incentives – or ‘carrots’ and ‘sticks’ – is of limited use in distinguishing those incentive schemes that raise concerns of equality from those that do not. The paper assesses incentive schemes with respect to two important considerations of equality: equality of access and equality of outcomes. While our assessment of incentive schemes will, ultimately, depend on various empirical facts, the paper aims to advance the debate by identifying some of the empirical questions we need to ask. The paper concludes by considering a number of trade-offs and caveats relevant to the assessment of incentive schemes.


Corresponding author

*Correspondence to: Kristin Voigt, Department of Politics, Philosophy & Religion, Lancaster University, Lancaster, UK. Email:


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Bains, N., Pickett, W., Laundry, B.Mercredy, D. (2000), ‘Predictors of smoking cessation in an incentive-based community intervention’, Chronic Diseases in Canada, 21(2): 5461.
Ballard, P.Radlet, A. (2009), ‘Give it up for baby: a smoking cessation intervention for pregnant women in Scotland’, Cases in Public Health Communication & Marketing, 3: 147160.
Barbeau, E., Wolin, K., Naumova, E.Balbach, E. (2005), ‘Tobacco advertising in communities: associations with race and class’, Preventive Medicine, 40(1): 1622.
Bishop, G.Brodkey, A. (2006), ‘Personal responsibility and physician responsibility—West Virginia’s Medicaid plan’, New England Journal of Medicine, 355(8): 756758.
Braun, B., Reiners, H., Rosenwirth, M.Schlette, S. (2006), Anreize zur Verhaltenssteuerung im Gesundheitswesen: Effekte bei Versicherten und Leistungsanbietern, Gütersloh: Bertelsmann Stiftung.
Cahill, K.Perera, R. (2008), ‘Competitions and incentives for smoking cessation’, Cochrane Database of Systematic Reviews, 3 Art. No.: CD004307, doi:10.1002/14651858.CD004307.pub3.
Carrell, S. (2008), ‘Pupils earn just reward for healthy eating’, The Guardian, 3 November.
Claassen, D. (2007), ‘Financial incentives for antipsychotic depot medication: ethical issues’, Journal of Medical Ethics, 33(4): 189193.
Claassen, D., Fakhoury, W., Ford, R.Priebe, S. (2007), ‘Money for medication: financial incentives to improve medication adherence in assertive outreach’, Psychiatric Bulletin, 31(1): 47.
Cookson, R. (2008), ‘Should disadvantaged people be paid to take care of their health? Yes’, British Medical Journal, 337: 140.
Daniels, N. (2008), Just Health: Meeting Health Needs Fairly, Cambridge: Cambridge University Press.
Daniels, N. (forthcoming), ‘Individual and Social Responsibility for Health’, in C. Knight and Z. Stemplowska (eds), Distributive Justice and Responsibility, Oxford and New York: Oxford University Press.
Daniels, N.Sabin, J. (2008), Setting Limits Fairly: Learning to Share Resources for Health, 2nd edn, New York: Oxford University Press.
Das, J., Do, Q.Ozler, B. (2005), ‘Reassessing conditional cash transfer programs’, The World Bank Research Observer, 20(1): 5780.
Devine, C. M., Jastran, M., Jabs, J., Wethington, E., Farell, T. J.Bisogni, C. A. (2006), ‘ “A lot of sacrifices”: work-family spillover and the food choice coping strategies of low-wage employed parents’, Social Science and Medicine, 63(10): 25912603.
Dudley, R., Tseng, C., Bozic, K., Smith, W.Luft, H. (2007), Consumer Financial Incentives: A Decision Guide for Purchasers, Rockville, MD: Agency for Healthcare Research and Quality, AHRQ Publication No. 07(08)-0059.
Dworkin, R. (1981), ‘What is equality? Part 2: equality of resources’, Philosophy & Public Affairs, 10(4): 283345.
Eckholm, E. (2006), ‘Medicaid plan prods patients toward health’, New York Times, 1 December.
Families USA (2008a), ‘Mountain Health Choices: An Unhealthy Choice for West Virginians’, [4 June 2009].
Families USA (2008b), ‘Reward/Penalty Plans for Wellness: Coming Soon to an Office Near You?’ [14 February 2010].
Federal Register (2006), ‘Nondiscrimination and wellness programs in health coverage in the group market; final rules’, Federal Register, 71(239): 7501475055, December 13.
Florida Agency for Health Care Administration (2005), ‘Florida Medicaid Reform Application for 1115 Research Demonstration and Waiver’, [15 February 2010].
Forde, I.Zeuner, D. (2009), ‘Financial incentives to promote social mobility’, British Medical Journal, 339: 544546.
Graham, H. (1993), When Life’s a Drag: Women, Smoking and Disadvantage, London: Department of Health.
Greene, J. (2007), Medicaid Efforts to Incentivize Healthy Behaviors, Center for Health Care Strategies, Inc.,
Guttman, N.Ressler, W. (2001), ‘On being responsible: ethical issues in appeals to personal responsibility in health campaigns’, Journal of Health Communication, 6(2): 117136.
Guttman, N.Salmon, C. T. (2004), ‘Guilt, fear, stigma and knowledge gaps: ethical issues in public health communication interventions’, Bioethics, 18(6): 531552.
Hand, L. (2009), ‘Carrots and sticks: employers prod workers to adopt behaviors to improve health’, Harvard Public Health Review, Winter 2009: 49.
Hilzenrath, D. (2009), ‘Wellness incentives could create health-care loophole’, Washington Post, 16 October.
Jetter, K.Cassady, D. (2006), ‘The availability and cost of healthier food alternatives’, American Journal of Preventive Medicine, 30(1): 3844.
Jochelson, K. (2007), Paying the Patient: Improving Health Using Financial Incentives, London: King’s Fund.
Kahneman, D.Tversky, A. (1979), ‘Prospect theory: an analysis of decision under risk’, Econometrica, 47(2): 263291.
Kerpelman, L., Connell, D.Gunn, W. (2000), ‘Effect of a monetary sanction on immunization rates of recipients of aid to families with dependent children’, The Journal of the American Medical Association, 284(1): 5359.
Khaw, K.-T., Wareham, N., Bingham, S., Welch, A., Luben, R.Day, N. (2008), ‘Combined impact of health behaviours and mortality in men and women: the EPIC-Norfolk prospective population study’, PLoS Medicine, 5(1): 3947.
Lagarde, M., Haines, A.Palmer, N. (2007), ‘Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries’, The Journal of the American Medical Association, 298(16): 19001910.
Laken, M.Ager, J. (1995), ‘Using incentives to increase participation in prenatal care’, Obstetrics & Gynecology, 85(3): 326329.
Le Grand, J.Srivastava, D. (2009), Incentives for Prevention, London: Health England.
Marcus, A. C., Crane, L. A., Kaplan, C. P., Reading, A. E., Savage, E., Gunning, J., Bernstein, G.Berek, J. S. (1992), ‘Improving adherence to screening follow-up among women with abnormal pap smears: results from a large clinic-based trial of three intervention strategies’, Medical Care, 30(3): 216230.
Marmot, M.Wilkinson, R. G. (eds) (2005), Social Determinants of Health, 2nd edn, Oxford: Oxford University Press.
Marteau, T. M., Ashcroft, R. E.Oliver, A. (2009), ‘Using financial incentives to achieve healthy behaviour’, British Medical Journal, 338: b1415.
McColl, K. (2008), ‘New York’s road to health’, British Medical Journal, 337: a673.
Mechanic, D. (2002), ‘Disadvantage, inequality, and social policy’, Health Affairs, 21(2): 4859.
Mello, M.Rosenthal, M. (2008), ‘Wellness programs and lifestyle discrimination—the legal limits’, New England Journal of Medicine, 359(2): 192199.
Okie, S. (2007), ‘The employer as health coach’, New England Journal of Medicine, 357(15): 14651469.
Oliver, A. (2009), ‘Can financial incentives improve health equity?’, British Medical Journal, 339: 705706.
Oliver, A. (forthcoming), ‘Reflections on the development of health inequalities policy in the United Kingdom’, Health Care Analysis.
Phillips, A. (2004), ‘Defending equality of outcome’, Journal of Political Philosophy, 12(1): 119.
Popay, J. (2008), ‘Should disadvantaged people be paid to take care of their health? No’, British Medical Journal, 337(7662): 141.
Post, E., Cruz, M.Harman, J. (2006), ‘Incentive payments for attendance at appointments for depression among low-income African Americans’, Psychiatric Services, 57(3): 414416.
Redmond, P., Solomon, J.Lin, M. (2007), Can Incentives for Health Behavior Improve Health and Hold Down Medicaid Costs?, Washington, DC: Center on Budget and Policy Priorities.
Schmidt, H. (2007), ‘Personal responsibility for health—developments under the German Healthcare Reform 2007’, European Journal of Health Law, 14(3): 241250.
Schmidt, H. (2008), ‘Bonuses as incentives and rewards for health responsibility: a good thing?’, Journal of Medicine & Philosophy, 33(3): 198220.
Schmidt, H. (2009), ‘Personal responsibility in the NHS Constitution and the social determinants of health approach: competitive or complementary?’, Health Economics, Policy and Law, 4(2): 129138.
Schmidt, H., Gerber, A.Stock, S. (2009), ‘What can we learn from German health incentive schemes?’, British Medical Journal, 339: 725728.
Schmidt, H., Voigt, K.Wikler, D. (2010), ‘Carrots, sticks, and health care reform – problems with wellness incentives’, New England Journal of Medicine, 362(2): e3(1)e3(3).
Schnee, M. (2007), ‘Neue Versorgungs- und Versicherungsformen in der GKV: Wer kennt sie und wer nutzt sie?’, Gesundheitsmonitor, 2: 19.
Sindelar, J. (2008), ‘Paying for performance: the power of incentives over habits’, Health Economics, 17(4): 449451.
Sutherland, K., Leatherman, S.Christianson, J. (2008), Paying the Patient: Does It Work? A Review of Patient-targeted Incentives, London: The Health Foundation.
Tester, J.Baker, R. (2009), ‘Making the playfields even: evaluating the impact of an environmental intervention on park use and physical activity’, Preventive Medicine, 48(4): 316320.
Voigt, K., Schmidt, H. (2010), ‘Wellness programs: a threat to fairness and affordable care’, Hastings Center Health Care Cost Monitor, [13 January 2010].
Volpp, K. G., Troxel, A. B., Pauly, M. V., Glick, H. A., Puig, A., Asch, D. A., Galvin, R., Zhu, J., Wan, F., DeGuzman, J., Corbett, E., Weiner, J.Audrain-McGovern, J. (2009), ‘A randomized, controlled trial of financial incentives for smoking cessation’, New England Journal of Medicine, 360(7): 699709.
Wanless, D. (2003), Securing Good Health for the Whole Population: Population Health Trends, London: HMSO.
Warner, K.Murt, H. (1984), ‘Economic incentives for health’, Annual Review of Public Health, 5(1): 107133.
Wikler, D. (1978), ‘Persuasion and coercion for health: ethical issues in government efforts to change life-styles’, Millbank Memorial Fund Quarterly, 56(3): 303327.
Wilkinson, E. (2008), ‘Can you pay people to be healthy?’, Lancet, 371(9621): 13251326.

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Incentives, health promotion and equality

  • Kristin Voigt (a1)


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