Rewarding citizens for preventive health? A controversial idea - but one that works
Offering citizens financial incentives to adopt healthy behaviors may sound debatable, yet it is already a widespread practice in several high- and upper-middle-income countries, with impressive results. A group of researchers from SDA Bocconi, the Universities of Pavia and Milano-Bicocca, and the Lombardy Region conducted analyzing 27 programs promoted by public institutions or insurance companies that used tools such as vouchers, prepaid cards, or insurance premium discounts to encourage physical activity, vaccinations, screening, quitting smoking or substance abuse recovery.
The results show that incentives go a long way to help people adopt and maintain preventive behaviors, especially when these incentives are linked to concrete, measurable goals (for example, tracking daily steps with a wearable device or finishing a complete vaccination cycle).
However, the study warns about two critical issues. The first concerns economic sustainability, since not all programs include robust cost-effectiveness evaluations. The second relates to how long the observed benefits will last once the incentive is gone, an aspect rarely studied among the programs reviewed by the researchers.
The context
Population aging and the growing burden of chronic diseases are putting immense pressure on healthcare systems. In Europe, half of the population will be over 50 years old by 2030. And already today, cardiovascular diseases, cancer, diabetes, and respiratory illnesses absorb most healthcare spending and account for up to 90% of deaths in the European Union.
In Italy, chronic diseases represent about 70% of national healthcare expenditure, a number that hits 80% in regions such as Lombardy. Prevention is widely recognized as the most cost-effective strategy: It improves clinical outcomes, enhances quality of life, reduces direct and indirect costs, and contributes to greater productivity.
Yet efforts made so far in healthcare systems have fallen short of expectations; the incidence of chronic diseases and risk factors such as obesity continues to rise. And it’s not just a question of limited investments. (In OECD countries, prevention accounts for just 2–4% of healthcare spending.) It’s also about cognitive and motivational barriers. In fact, individuals often struggle to make healthy choices when the benefits materialize only in the medium to long term.
This brings us to the research question: Can financial incentives help overcome these barriers?
The research
The team in countries such as the United States, the United Kingdom, Canada, Germany, Japan, and Singapore.
These programs fall into two main categories:
- Multidimensional (44%): targeting several behaviors simultaneously (walking, getting vaccinated, having periodic check-ups)
- Vertical, focused on a single preventive goal:
- Vaccinations (19%): from childhood to the COVID-19 emergency
- Physical activity (19%): with daily or weekly activity targets
- Smoking cessation and substance abuse recovery (15%)
- Sexually transmitted diseases (4%)
Incentives range from small daily rewards worth a few cents to substantial insurance benefits, exceeding $2,500 per year in some experimental programs in the United States. Most initiatives offer guaranteed rewards (87%), though some rely on lotteries.
Notable examples include:
- National Steps Challenge (Singapore): a program distributing wearable devices and awarding vouchers for reaching daily step targets (up to $43 per year), leading to a measurable upswing in physical activity.
- Vitality Program (South Africa, Canada, USA): an insurance initiative offering discounts and benefits for check-ups, physical activity, and screenings, with proven reductions in hospital costs.
- Vax-a-Million Lottery (Ohio, USA): a lottery with prizes of up to one million dollars to encourage COVID-19 vaccinations, showing positive (though variable) effects.
As for impact evaluation, 63% of programs provided evidence that incentives successfully increased daily steps and vaccination rates, as well as the number of people going in for their screenings and even abstaining from drugs. All that said, data on avoided costs and structural savings remain limited and inconsistent, and few studies measure whether behaviors persist once incentives are removed.
Conclusions and takeaways
The review confirms that financial incentives are effective tools for rapidly activating healthy behaviors. However, they are not sufficient on their own. In fact, they risk producing short-term effects without fostering intrinsic motivation.
For policymakers, three key takeaways emerge:
- Combine multiple tools. Financial incentives can act as an effective “initial switch,” but they should be paired with educational campaigns and engagement tools to promote awareness and responsibility.
- Assess costs and equity. More evidence is needed on cost-benefit ratios and redistributive impacts, as it’s still unclear whether and when such programs generate systemic savings.
- Personalize incentives. A one-size-fits-all approach does not always work. More flexible models, tailored to individual needs and preferences, could deliver better results.
Financial incentives are not a miracle shortcut, but they can be useful when integrated into a broader health-promotion strategy. The challenge lies in implementing them sustainably, so that they’re not simply a short-term cost; instead they evolve into an investment generating long-term economic and social benefits.
, , Francesca Sala, Guido Bertolaso, Lorenzo Menichelli, Riccardo Vecchio, , “,” Social Science & Medicine, Volume 383, 2025, 118499, DOI: .
