“For money you can have everything it is said. No, that is not true. You can buy food, but not appetite; medicine, but not health; soft beds, but not sleep; knowledge, but not intelligence; glitter, but not comfort; fun, but not pleasure; acquaintances, but not friendship; servants, but not faithfulness; grey hair, but not honour; quiet days, but not peace. The shell of all things you can get for money. But not the kernel. That cannot be had for money.”

-          Arne Garborg (1851-1924)

 I recently read of a proposed scheme to enhance the uptake of immunisation by paying parents whose children complete the full schedule (1).

This article made me wonder when it started to become necessary to pay people to engage in what is widely regarded (within the healthcare community at least) as the socially responsible course of action? When did doing the right thing stop being its own reward?

Let us re-consider the pitch to a sense of community and both individual and social responsibility. Or, let us at least avoid pitching to the wallet.  The more we do this, the more we encourage people to make their decisions based on economic impact at the individual level. Sure, it is important, but what a tragically narrow, and ultimately unsustainable view.

Research tells us that people prioritise happiness. They also desire healthy, safe and cohesive communities. Immunisation is not the way forward to these outcomes, but it is part of a way forward to achieving our aims. Immunisation benefits population health (and how), it is generally very safe and, in addition to the oft-forgotten personal gain, it represents a small but real way that we can contribute to the society in which we live. Why have we lost this message from our sales pitch and instead resorted to cash argument? It feels lazy. And it is just so predictable.

When we consider shifting perceptions, we must recognise that we have the capacity to move thinking in more than one direction: we can in fact shift people backward. Locking the bar at the level of economic reward is an insult to our society. It does not represent progress. We need to be asking whether or not we are content with this approach being the signpost or even the accepted standard for how individual priorities should be set.  When we have a choice, why chose to not only perpetuate but also actively bolster a cash-obsessed culture? What else do we value?

In a country that proclaims to be proud a system that enables universal access to healthcare, let us take a step back and re-think the message delivered by such ‘incentive schemes’. Let us halt the approach that manipulates the message to one focused on health as a business. As Garborg said, health cannot be bought. Why should our health-related decisions be any different?

Don’t get me wrong: I’m a fervent fan of incentives. I am barely out of bed each morning before the words; “we’ve got to make the healthy choice the easy choice” find their way out of my mouth. But, in many ways immunisation is already incentivised. It is free. For most, information and the vaccines themselves are readily available and many reasonable steps have already been taken to ensure that the preferred choice (that of uptake) is an easy option for parents/guardians.

The more we advertise a certain approach, the more we (inadvertently or otherwise) encourage people to align themselves with it. The more we vocalise the view that “well, money talks”, the more we act to silence the other voices around us. The voices that tell us to recognise the inherent reward in doing what you think is both right and best. The sense that simply contributing to the system from which we all benefit is reason enough.

It seems that we are incredibly hesitant to appeal to an individual’s sense of duty – to themselves and the wider community. Why? We are told it is preachy and coercive. And yet we appear to be comfortable whipping out the country’s credit card to effectively buy a decision. Simply telling ourselves how different the respective approaches are does not make them so.

The bottom line here is that when we attempt to buy the general public’s take-up of a health initiative, we sell Kiwi’s short. We can do so much better.

1. Martin Johnston (New Zealand Herald). ‘Govt eyes cash offer for kids immunisation’. Thursday 23 June 2011. URL: http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10733956