correspondence
A randomized controlled trial to test financial
incentives for COVID-19 vaccination in Ghana
To the Editor — Achieving high levels of uptake from studies in lower- and The Ghana Financial Incentives study
vaccine uptake across Africa will be critical middle-income countries (LMICs)5. is an RCT designed primarily to determine
to achieving global COVID-19 vaccination. Nevertheless, a recent review suggests the whether cash incentives, which participants
Cash incentives have been proposed as a way impact of cash incentives in LMICs have are informed about via a video message,
to improve the efficiency and equity of the been under-studied6. The COVID-19 increase uptake of COVID-19 vaccines. In
roll-out in Africa1. While there is a large body pandemic has ratcheted up the need to addition, we also explore: the relative effect
of experimental evidence suggesting that understand whether financial incentives of cash incentives versus providing health
financial incentives can promote healthcare are an effective policy tool for promoting information; how different levels of cash
use2, studies on the promotion of COVID-19 vaccinations, particularly in an African incentives may influence vaccine uptake;
vaccination uptake from high-income context. Accordingly, we are undertaking and the potential for spillover effects of
countries have had mixed results. Large an RCT in rural districts in Ghana that incentives, whereby providing financial
randomized controlled trials (RCTs) of addresses whether cash incentives of incentives in the treatment arm may affect
financial incentives in Sweden and the USA different magnitudes affect the willingness vaccine uptake among others who have not
have produced conflicting results about their to get vaccinated against COVID-19; at been treated.
effect on the uptake of COVID-19 vaccines3,4. the same time we will assess the policy Beyond the effect of financial incentives
There have been some encouraging implications of scaling up a programme of on vaccine uptake, there is also the broader
results regarding incentives and vaccination financial incentives for vaccinations (Fig. 1). question of the costs and benefits of such
Treatment phase
District level; treated villages including 4 treatments; Objective
January–April 2022 untreated villages including 2 categories
Treatment delivery (video message); treated Untreated villages neighboring within 10 km
villages including control treatment, standard to treated; not neighbouring within 10km Treatment
health message, low cash incentive, high delivery
cash incentive (video message)
Control treatment; Standard health Low cash High cash Neighbor to treated Neighbor to treated
placebo treatment message treatment treatment treatment village (≤10 km) village (>10 km)
Verification of vaccination status; Measuring direct
Telephone/WhatsApp; in-person survey treatment effects
for non-respondents (+6 weeks)
Post-treatment phase Measuring indirect
Verification of vaccination status; (spillover)
May 2022 treatment effects
in-person survey
(+6 weeks):
within-village level
Measuring indirect
Verification of vaccination status; (spillover)
in-person survey treatment effects:
across-village level
Follow-up phase (+2 weeks) Baseline health
Telephone/WhatsApp survey
May 2022 behaviour
Follow-up phase (+6 months) Endline health
Telephone/WhatsApp
November 2022 behaviour
Fig. 1 | Flow chart of the Ghana Financial Incentives experiment. The figure summarizes the random cluster design for one of the six districts. Villages are
randomly assigned to one of four 45-second video treatments in the experiment: a placebo video (concerning solar charging devices); a health message; an
offer of $3 if vaccinated; and an offer of $10 if vaccinated. The 45-second video treatment is administered to participants on a tablet. 20 enumerators contact
randomly selected households and administer random assignment of videos that contain information about one of the four interventions. At the end of this
first treatment phase, 6 weeks after the initial intervention, all 6,500 participants are contacted via telephone to determine their vaccination status. This is the
primary outcome of the first phase of the study.
1516 Nature Medicine | VOL 28 | August 2022 | 1516–1522 | www.nature.com/naturemedicine
correspondence
a policy intervention. A US$11 vaccine A post-treatment phase of the RCT will 1
Nuffield College, University of Oxford, Oxford, UK.
incentive, which has recently been proposed1 occur approximately two months after the 2
University of Ghana, Accra, Ghana. 3Hitotsubashi
for Africa would cost in the order of $9 initial intervention, when enumerators will Institute for Advanced Study, Hitotsubashi University,
billion if implemented across the continent. contact all treated participants who indicate Tokyo, Japan. 4Centre for Experimental Social
A key issue that can be informed by our they have been vaccinated, in order to verify Sciences, University of Santiago of Chile (USACH),
study is to identify the levels of financial their vaccine certificates. During this phase Santiago, Chile. 5Health Economics Research
incentives that would be most cost-effective. a sample of approximately 3,500 households Centre, Nuffield Department of Population Health,
We designed the Ghana Financial from neighboring non-treated villages University of Oxford, Oxford, UK. 6University of
Incentives project with a view to assessing will be surveyed to determine their rate of Melbourne, Melbourne, Victoria, Australia.
the broader indirect consequences of a vaccine uptake during the six-month period ✉e-mail:
[email protected]vaccine incentive policy initiative. There is a following the initial video treatments. These
general concern that financial incentives can verified vaccinations from non-treated Published online: 16 June 2022
undermine intrinsic motivations7 and hence participants will facilitate the estimation of https://doi.org/10.1038/s41591-022-01876-2
could have net social costs. This concern has spillover effects of the treatments.
been specifically articulated with respect to A final follow-up phase of the experiment References
1. Arezki, R. Nature 596, 9 (2021).
incentives and vaccines8. Building on a recent will allow us to estimate whether financial 2. Lagarde, M., Haines, A. & Palmer, N. Cochrane Database Syst.
evaluation framework9, we anticipate refining incentives have intended or unintended Rev. https://doi.org/10.1002/14651858.CD008137 (2009).
3. Campos-Mercade, P. et al. Science 374, 879–882 (2021).
our estimate of the social benefits of financial consequences for the longer-term health 4. Chang, T. et al. Financial Incentives and Other Nudges Do Not
incentives for vaccination by estimating the behavior of participants who were affected Increase COVID-19 Vaccinations among the Vaccine Hesitant
causal spillover effect of the interventions. (both in treatment and in spillover) by Working Paper 29403 (NBER, 2021).
The design addresses two dimensions the financial incentive treatments. We will 5. Gibson, D. G. et al. Lancet Glob. Health 5, 428–438 (2017).
6. Merriam, S. & Behrendt, H. Increasing Vaccine Uptake in Low-
that should be considered in scaling up a implement a baseline survey and then a and Middle-Income Countries (Behavioural Insights Team, 2020).
vaccine program: spillovers and treated six-month follow-up to collect information 7. Gneezy, U., Meier, S. & Rey-Biel, P. J. Econ. Perspect. 25,
participants. Following a recent African on: health attitudes and behavior; vaccine 191–210 (2011).
8. Promberger, M. & Marteau, T. M. Health Psychol. 32,
RCT10 we explicitly incorporate design attitudes and behavior; and vaccination 950–957 (2013).
features that will allow us to estimate the status, including information on second 9. Fletcher, J. & Marksteiner, R. Am. Econ. J. Econ. Policy 9,
geographic spillover effect of the cash doses and booster shots. 144–166 (2017).
10. Giné, X. & Mansuri, G. Am. Econ. J. Appl. Econ. 10,
incentive treatments, which can come The initial challenge for ensuring 207–235 (2018).
from diffusion of information about cash COVID-19 vaccination coverage in Africa
payments. A second concern is that cash was the limited availability of vaccine Acknowledgements
incentives will have unintended, and supplies. In the future, the number of This research was supported by funding from the NIHR
potentially negative, consequences for people willing to be vaccinated may be the Oxford Biomedical Research Centre, Hitotsubashi Institute
future health-related behavior. An extended main constraint on global efforts to control for Advanced Study and the University of Santiago, Chile.
M.V. is partly supported by the NIHR Applied Research
follow-up with treated participants is being the COVID-19 pandemic. Randomized Collaboration Oxford and Thames Valley. The views
planned in order to address this question. experiments of incentives and health expressed are those of the authors and not necessarily those
Ghana is classified as a low-income messaging can have an important role of the NIHR or the Department of Health and Social Care.
country with a GDP per capita of just under in designing effective policies that will
$2,000, though it has experienced high rates maximize global COVID-19 vaccination Author contributions
of economic growth in recent years. The coverage. ❐ All authors were involved in the conceptualization of this
correspondence. R.D., E.A. and P.C. were involved in
participant population for the trial is from overall study design. P.C. and R.D. prepared the first draft.
six rural districts, which tend to be less Raymond Duch 1, Edward Asiedu 2, All authors were involved in reviewing and editing.
developed than urban areas. The field work Ryota Nakamura 3, Thomas Rouyard3,
for the study is being undertaken by a team Carlos Yevenes4, Laurence Roope 5, Competing interests
from the University of Ghana. Mara Violato 5 and Philip Clarke 5,6 ✉ The authors declare no competing interests.
Questions of accountability and transparency
in the US organ donation and transplantation
system
To the Editor — The US federal government Network (OPTN), that the transplant Young (R-IN.) and Ben Cardin (D-MD.)
has made it clear, in both the National system requires increased transparency, sent the United Network for Organ Sharing
Organ Transplant Act (PL 98-507) and accountability, and policy that is evidence (UNOS) a request for information and data
the Final Rule (42 CFR 121), which based and equitable1–3. To illustrate this, in February 2020, after “recent reports of
established the regulatory framework Senate Finance Committee Chairman lapses in patient safety, misuse of taxpayer
for the structure and operation of the Chuck Grassley (R-IA), Ranking Member dollars, and tens of thousands of organs
Organ Procurement and Transplantation Ron Wyden (D-Ore.), and Senators Todd going unrecovered or not transplanted”4
Nature Medicine | VOL 28 | August 2022 | 1516–1522 | www.nature.com/naturemedicine 1517
