By Robert Slonim, Professor, University of Sydney School of Economics
Blood shortages remain a large global public health concern with shortages worldwide, often severe in developing countries, and seasonal shortages remain common in many developed countries. With less than 10 percent of the population donating in developing countries, and much less in less wealthy countries, the need for increasing the blood supply remains an important public policy concern.
Institutions such as the World Health Organization and many national blood agencies have for 40 years promoted policy guidelines that oppose the use of economic incentives to attract blood donors. In an article that appears in the May 24, 2013, issue of Science, Nicola Lacetera, Mario Macis and I argue that such opposition should be reconsidered based on new evidence.
The opposition has been based in part on two empirically testable notions. First, paying donors could undermine altruistic motivation for blood donations and result in fewer donations than a purely volunteer blood donation supply. Second, economic incentives may attract donors with less safe blood supply, such as those with a higher incidence of Hepatitis or HIV. Over the past 40 years many surveys and laboratory studies have found evidence that in general support these concerns. In our paper we note, however, that this evidence comes mainly from uncontrolled studies using non-random samples, and surveys and artificial scenarios using hypothetical questions. Along with other researchers, we have been investigating whether this evidence would hold up in actual blood donation situations.
In our Science paper, we review a large body of very recent field-based evidence from large, representative samples on actual donations, and the results clearly refute the previous findings: economic rewards have a positive effect on donations, without negative consequences on the safety of the blood. This evidence comes from the work of other researchers along with our own extensive work. The evidence comes from studies examining the effects of actual incentives for actual blood donors in the United States, Argentina, Switzerland and Italy. Of the 19 incentive items examined using field-based methods, 18 had a positive effect and only one (a free cholesterol test) had no effect. The incentives ranged from mostly small valued items such as t-shirts and $5 gift cards to a paid day off work. We also note that in every study that was able to observe the quality of the donation, as measured by whether donors were deferred or the blood was later rejected during safety tests, none found any significant changes in the usability of the blood. Thus, in contrast to the earlier evidence, the field-based evidence clearly indicates that economic incentives can increase the blood supply without any negative consequences for the safety of the supply.
There are many differences between the earlier approaches and the new evidence that can explain the radically different results. For instance, in the field studies donors do not feel scrutinized by the researcher and thus might be less concerned about their image and more excited about the rewards. Moreover, the past research often focused on getting paid cash to donate, whereas offering “gifts” such as t-shirts may be seen as a token of appreciation which can reinforce rather than undermine donors’ intrinsic motivation. Also, the rewards are typically provided for presenting at the blood drives, not for donating blood, which should reduce the risk that an ineligible donor might misrepresent health or other information.
There is a wide gulf between “paying donors,” which has been opposed by the WHO and national blood banks, and a purely voluntary donation system. Offering small gifts falls within this gap, but many other policies are also possible. We conclude in our article that “In addition to economic incentives, policy-makers should consider non-pecuniary rewards (e.g., symbolic and with social recognition) and various appeals. Debates on ethical issues around giving rewards for donations should be encouraged. But there should be little debate that the most relevant empirical evidence shows positive effects of offering economic rewards on donations.
You can read the abstract here: http://www.sciencemag.org/content/340/6135/927.summary.