How It Works

Many mothers in northern Nigeria live on less than $2 a day and cannot visit the clinic for various reasons. They face challenges such as affording the transportation cost to the clinic, associated loss in earnings from small-scale trading or farming, receiving permission from their partners, fear of vaccination side effects, cultural barriers to vaccination, or often a combination of these factors. Working within government clinics and in conjunction with existing programs, we provide small cash incentives to caregivers after verifying that their infant has gotten the latest vaccinations. The six transfers given during six visits to the clinic in the first year of the infant’s life total ~USD $11, enough to cover transport, medicine, and food for their families.

Poor mothers in rural West Africa are stuck in a cycle of poverty. Living at the bottom of the economic ladder forces them to make choices between their survival today and a better future for them and their children tomorrow. With a small cash incentive, caregivers do not have to worry about missing work and can afford transport to access health clinics. Put simply, they no longer have to choose between food today or health tomorrow. The impact is profound: children are protected against deadly diseases.

Vaccination is one of the most cost-effective public health interventions in the world (Rémy, Zöllner, and Heckmann, 2015), but childhood routine vaccination rates are persistently low in some areas of the world, including northern Nigeria. New Incentives developed the All Babies program in response to a body of evidence that conditional cash transfers can improve health behavior (see, for example, Bastagli et. al., 2015), evidence that small incentives can significantly increase vaccination rates (see Banerjee et al., 2010), and other behavioral science research on the power of small incentives (see examples). Altogether, the research suggested that small cash incentives could be an extremely cost-effective way to increase vaccination rates in areas where rates are low, but a randomized evaluation had not been conducted on this exact model or in the context of northern Nigeria. Therefore, before scaling up, New Incentives decided to have its model rigorously tested with a randomized controlled trial. The trial, conducted by IDinsight and Hanovia Limited, found that the program doubled the percentage of infants who were fully immunized, increasing coverage from roughly a quarter to just over half of all infants. (For more details, see the Evidence section and other answers below.)

A randomized controlled trial or RCT is regarded as the gold standard for evaluating the effectiveness of an intervention. With an RCT, people are allocated at random (by chance alone) to receive an intervention or be part of a control group that does not receive the intervention at the time of the study, creating groups that are comparable. The control group allows researchers to establish a “counterfactual” to know what would have happened in the absence of the program. Researchers compare outcomes between groups over time, and any differences that emerge can be attributed to the intervention. An RCT is the best way to establish a causal effect of an intervention, helping organizations know with confidence what their work actually does and does not do.

The evaluation found that the program substantially increased vaccination coverage for children between 12 and 16 months of age. Children living in the catchment areas of program clinics had 16 percentage points higher coverage of the BCG vaccine, 21 percentage points higher coverage of the first dose of pentavalent vaccine, and 14 percentage points higher coverage of measles vaccine. Importantly, the program doubled the percentage of infants who were fully vaccinated (BCG, Penta 1-3, and MCV), increasing coverage from roughly a quarter to just over half of all infants. The RCT also found that the program had improved the timeliness (within one month) of the measles vaccine, optimizing the protection of the vaccine. Additionally, program clinics were more likely to report no or rare stockouts than control clinics, suggesting that the program’s impact may go beyond stimulating vaccine demand to also reduce vaccine supply constraints.

Yes. Vaccination provides immunity that is sustained throughout a person’s life. Increasing vaccination rates also increases the proportion of a population that is immune to a disease, making disease outbreaks less likely in the future. In addition, this model was shown through rigorous, independent evaluation to have other positive effects that contribute to sustainability such as positive effects on knowledge and attitudes about vaccines in the areas covered by the program. This result suggests the caregivers may be more likely to have other children vaccinated in the future and that the program may have effects on their family and neighbors as well, though further research would be needed to confirm this.

New Incentives focuses on using evidence-based methods to make programmatic decisions and to do the most good possible per dollar spent. Some examples of how we do this: we designed our program based on evidence on conditional cash transfers, an approach that has proven to be effective in changing health behaviors; we focus on immunizations and operate in northern Nigeria, where only around 25% of infants are fully immunized (thus leading to devastating disease outbreaks); and we base operational decisions on rigorous data collection to increase program effectiveness and efficiency.

New Incentives operates where it can have the biggest impact: rural Nigeria. The West African country is home to just 3% of the world’s population, yet accounts for 13% of the world’s mortality of children under five, the second highest rate in the world.

Yes. Donations to New Incentives made in the US are tax-exempt under section 501(c)(3) of the Internal Revenue Code. Contact us if you'd like to donate from outside the US.

There is no strong evidence to suggest that small incentives reduce intrinsic motivation to get vaccinated. We believe this may be because the small size of the transfer acts more as a behavioral “nudge”—helping caregivers get over the hurdle of getting to the clinic—as opposed to providing a real monetary “reward.” However, there is some evidence that larger transfers can dampen intrinsic motivation. This is something that we and other organizations continue to assess and consider as the evidence base grows.

One of our core responsibilities is fraud mitigation and preventing potential leakage of funds. We have comprehensive procedures and systems to prevent and detect fraud. We carry out post transfer reviews of each disbursement, regularly perform unannounced program audits, and have robust data analytics that we continuously iterate based on lessons learned. We follow rigorous standards for recruiting, training, and managing our personnel.

New Incentives encourages timely vaccination recordkeeping and reporting, reviews vaccine stocks to help prevent vaccine stockouts, and provides support to government stakeholders to submit vaccine utilization reports. To assess vaccine quality, we work with clinic staff to review vaccine vial monitors (VVMs) and vaccine expiry dates, and call Local Cold Chain Officers (LCCOs) and State Cold Chain Officers (SCCOs) every other week to verify the stock and validity of vaccine supply. A documented review of availability of adequate stock is completed before each immunization day. Issues are resolved prior to the start of the session when escalated. Stockouts that occur during the session are also reported, and efforts are made to resolve before the next session. Our teams work with LCCOs and SCCOs to assess availability of adequate vaccines in stock for the next two weeks.

New Incentives actively participates with the State Emergency Routine Immunization Coordination Centre (SERICC) and has provided financial and technical supports such as: training of LGA Routine Immunization Officers, printing of data tools and materials for outreach with traditional leaders, support for SERICC infrastructure, collaboration with private clinics on routine immunizations, participation in supportive supervision, and quarterly earmarked financial support to SERICC on their choice of activities that strengthen routine immunization.