Maternal health is considered a key global priority by the World Health Organization, and several strategies are used to promote it. Especially in lower- and lower-middle-income countries, one widely used strategy employs financial incentives to motivate pregnant women to access available healthcare. While such interventions have been extensively empirically evaluated, their normative aspects appear to have received less attention. To address this gap, we systematically searched and reviewed normative and qualitative literature to map and analyze the ethical considerations of using (...) financial incentives to promote maternal health. Twenty-three articles (four normative and 19 qualitative) were included in the review. We grouped ethical considerations under six categories, namely the program structure, promoting institutional births, of the ethical significance of cash, justifying conditionalities for maternal health, effects on individuals’ decision-making and the experiences of vulnerable groups. While incentives could be used for beneficent goals, we show how they may emphasize global rather than local solutions, impose unfamiliar sociocultural values, unfairly expect behavior change and disempower individuals and groups. We argue that future maternal health policy, especially those targeting vulnerable groups and minorities, would benefit from taking these normative considerations into account. (shrink)

Journal of Political Philosophy, EarlyView.

Background There has been growing interest in the use of incentives to increase the uptake of health-related behaviours and achieve desired health outcomes at the individual and population level. However, the use of incentives remains controversial for ethical reasons. An area in which incentives have been not only proposed but used is HIV prevention, testing, treatment and care—each one representing an interconnecting step in the "HIV Cascade." Methods The main objective of this qualitative case study was to document the experiences (...) of health care and service providers tasked with administrating incentivized HIV testing, treatment, and care in British Columbia, Canada. A second objective was to explore the ethical and professional tensions that arise from the use of incentives as well as strategies used by providers to mitigate them. We conducted interviews with 25 providers and 6 key informants, which were analyzed using applied thematic analysis. We also collected documents and took field notes. Results Our findings suggest that incentives target populations believed to pose the most risk to public health. As such, incentives are primarily used to close the gaps in the HIV Cascade by getting the "right populations" to test, start treatment, stay on treatment, and, most importantly, achieve viral suppression. Participants considered that incentives work because they "bring people through the door." However, they believed the effectiveness of incentives to be superficial, short-lived and one-dimensional—thus, failing to address underlying structural barriers to care and structural determinants of health. They also raised concerns about the unintended consequences of incentives and the strains they may put on the therapeutic relationship. They had developed strategies to mitigate the ensuing ethical and professional tensions and to make their work feel relational rather than transactional. Conclusions We identify an urgent need to problematize the use of incentives as a part of the "HIV Cascade" agenda and interrogate the ethics of engaging in this practice from the perspective of health care and service providers. More broadly, we question the introduction of market logic into the realm of health care—an area of life previously not subject to monetary exchanges. (shrink)

Should financial incentives be offered to mothers for breastfeeding? Given the significant socioeconomic and sociodemographic differences in breastfeeding in the USA, researchers and policymakers are exploring the role of financial incentives for breastfeeding promotion with the objective of increasing uptake and reducing disparities. Despite positive outcomes in other health domains, the acceptability of financial incentives is mixed. Financial incentives in the context of infant feeding are particularly controversial given the complex obligations that characterize decisions to breastfeed. After situating the specific (...) ethical tensions related to personal responsibility, fairness, and intrusiveness, we argue that exploring carefully designed financial incentives can be ethically justified to support breastfeeding uptake particularly given established medical guidelines that support breastfeeding benefits, wide socioeconomic and racial/ethnic disparities and notable influences in the broader choice architecture of infant feeding in the USA. Additional empirical research is warranted to better understand effectiveness, cost and specific ethical concerns related to free and informed choice. (shrink)