This section below describes scientific evidence, expert guidance, and jurisdictional experiences regarding the effectiveness of incentives (primarily financial incentives) to improve COVID-19 vaccine uptake.

The following limitations should be noted:

• Limited information was available regarding outcomes of incentive programs targeting COVID-19 vaccines because such programs are still relatively new (mostly launched in May/June 2021). For this reason, evidence related to incentives designed to promote other health-related behaviours, including the uptake of other vaccines (e.g. influenza vaccines), was also included. The applicability of these findings to incentive programs in the context of COVID-19 is unknown.
• As of yet, there is no consensus in the identified literature regarding vaccine hesitancy or the explanations of why some people remain unvaccinated. Moreover, the unique circumstances surrounding the roll-out of the COVID-19 vaccines (including the unprecedented speed with which they were developed and approved, the urgency of the global pandemic, and the extent of the mobility restrictions imposed on unvaccinated individuals and communities) should be taken into consideration when evaluating these findings, as they may impact the effectiveness of incentive programs.
• Where expert guidance is cited, the recommendations are those of the authors of the original studies and the Research, Analysis, and Evaluation Branch does not have the expertise to evaluate such recommendations.

Scientific Evidence

The following conclusions were drawn from a review of 14 systematic reviews (three with meta-analyses) and 12 single studies articles. Of these, five single studies specifically discussed incentives to promote the uptake of COVID-19 vaccines, while the rest evaluated the effectiveness of incentives to either promote uptake of other vaccines (e.g., influenza, Human papillomavirus [HPV]) or modify other health-related behaviours.

Incentives for COVID-19 Vaccines:

• Incentive Type/Size:
  • Financial Incentives: There is mixed evidence of the effectiveness of financial incentive programs designed to improve the uptake of COVID-19 vaccines. 
    • Two studies based in the United States (US) conducted surveys to determine how incentives might affect individuals’ willingness to receive a COVID-19 vaccine. One study found that while uptake was improved by the removal of cost barriers (CAD $24 co-pay), financial incentives (of either CAD $12 or  CAD $120) did not increase willingness to vaccinate, although they did not discourage vaccination either. The other study (preprint) found that financial incentives between CAD $1,200 and CAD $2,400 yield an eight-percentage-point increase in vaccine uptake relative to baseline, though the study only measured self-reported vaccine intentions at one point in time, not actual behaviours.
    • One US study investigating COVID-19 vaccine incentives found that size of the cash transfer does not dramatically affect uptake rates.
  • Non-Financial Incentives: Two sources reviewed the implementation of Israel’s ‘Green Pass,’ a vaccine passport designed to improve COVID-19 vaccine uptake among the general population. While there is no direct evidence of the impact of this program on vaccine coverage, the results of one survey suggested that it may have led to an increase in willingness to be vaccinated: 31% of respondents said the offer of a Green Pass and the associated benefits would possibly or definitely persuade them to get vaccinated, whereas 46% said that incentives would not persuade them.
• Target Population: The studies identified targeted the general population in the United States (US) and Israel.
• Implementation: One article suggested that financial incentives are likely to discourage vaccination (particularly among those most concerned about adverse effects), and that non-financial incentives are preferred. Another commentary article noted that financial incentives are unlikely to persuade individuals to get vaccinated if they have concerns about the safety of the vaccine, for example due to the expedited development of the vaccines. Additionally, there is the risk that a financial incentive will be too large and may therefore have a coercive effect on vulnerable populations.

Incentives for Other Types of Vaccines:

• Incentive Type/Size:
  • Financial Incentives: Evidence regarding the effectiveness of financial incentives in promoting uptake of other vaccines was mixed, with eight systematic reviews finding some evidence that financial incentives (either alone or in combination with other interventions like outreach programs) increased vaccination uptake, and three reviews finding no evidence of effectiveness. However, among the eight systematic reviews that reported some evidence of a positive impact on vaccine uptake, three cautioned that further study was required and two noted the low quality of studies reviewed. The findings of two additional single studies suggested that financial incentives may boost vaccine uptake.
    • The effect that the size of the financial incentive may have on improving vaccine uptake in general was rarely examined in the surveyed literature. One systematic review found; however, some limited evidence that the effect of financial incentives on improving attendance for vaccination decreased as post-intervention follow-up period and incentive value increased.
  • Non-Financial Incentives: Two systematic reviews found that the use of rewards (e.g., gifts, cupcakes, raffle tickets, recognition for personal and work-group vaccination) was associated with an increase in vaccination uptake. One of the reviews, however, noted two important qualifications: 1) the target group in the study reviewed was very disadvantaged and as such the food-based incentive, so closely linked with basic survival, was unsurprisingly readily received; and 2) the baseline vaccination rates were very low (2%), which suggests that this target group was underserved and more likely to show greater outcome changes with an intervention.
• Target Population: The incentive programs covered in the literature targeted the general population, elderly, parents of school-age children, adolescents, individuals living in urban slums, people who inject drugs, health care workers, parents of new babies, and the vaccine hesitant. Some evidence for the effectiveness of incentives was found in programs targeting the general population, as well as for the following sub-populations: adolescents; individuals living in urban slums and low-income communities; health care workers; parents of school-age children; people who inject drugs’ and the elderly.
  • It should be noted, however, that one systematic review found no evidence that financial incentives (i.e., a lottery for free groceries) had any effect on improving the vaccination rate against influenza among individuals aged 60+ years.
• Implementation: A qualitative study found that there was little appetite for parental financial incentives designed to improve vaccination coverage among preschool-aged children, though financial incentives would be preferable to mandatory interventions. Moreover, universal incentives were more likely to be deemed acceptable by the public than targeted incentives.

Other Health-Related Behaviours:

• Incentive Type/Size:
  • Financial Incentives: Evidence drawn from systematic reviews of incentive programs designed to modify other health-related behaviours (e.g., prenatal care use, smoking cessation) was mixed. One systematic review found that financial incentive interventions were more effective than usual care or no intervention for encouraging healthy behaviour change; another found no evidence from reviews that examined the effect of financial incentives on patient outcomes; and a third concluded that there is insufficient evidence to fully evaluate the impact of incentives on prenatal care initiation. The evidence drawn from single studies was also mixed on incentive effectiveness:
    • One study found that conditional lottery incentives shortened the time to antiretroviral therapy (ART) initiation among South African men.
    • Another study found that non-cash financial incentives do not appear to affect the rate of specimen return in a chlamydia screening program among 16- to 24-year-olds in England.
• Target Population: The incentive programs covered in the literature targeted the general population, individuals aged 16-24 years in the United Kingdom (UK), pregnant women, and men living with HIV in South Africa. Some evidence for the effectiveness of incentives was found in programs targeting the general population, pregnant women, and men living with HIV in South Africa.
• Implementation: One UK study on the acceptability of financial incentives found that cash or shopping voucher-type financial incentives for healthy behaviours are not necessarily less acceptable than no incentives to adults. The study also noted that lower value incentives and those offered to all eligible individuals were preferred.

International Scan

Information was available on COVID-19 vaccine incentive programs for nine organizations at the federal level in the United States (US), 30 jurisdictions/organizations at the state level in the US, and 10 jurisdictions/organizations internationally (Australia, France, Hong Kong, Israel, Indonesia, Philippines, Saudi Arabia, Serbia, Russia, and United Arab Emirates).

• Incentive Type/Size:
  • In the US, 45 states, plus the District of Columbia, Puerto Rico, and the US Virgin Islands, have set up COVID-19 vaccine lotteries. Through public health departments and/or public private partnerships, a number of states have also offered prizes and other rewards. These incentives have been classified according to type, with categories such as: financial, scholarship, sports, transit, travel, experiences, food and drink, and other (e.g., provision of free childcare for adults seeking vaccine appointments or in need of backup while recovering from potential side effects; easing/termination of restrictions at a certain percentage vaccination rate). For example:
    • Ohio was one of the first states to offer cash incentives to combat vaccine hesitancy by launching the Vax-a-Million lottery on May 12, 2021, which offers a CAD $1.2 million prize to a vaccine recipient every week for five weeks, along with college scholarships for those aged 12-17 years.
    • California implemented a similar lottery program to the one in Ohio, offering vaccine recipients a chance to win 10 prizes of CAD $1.8 million, 30 prizes of CAD $60,000, and CAD $60 gift cards for two million others.
    • Oregonians 18 years and older have the chance to win CAD $1.2 million or one of 36 CAD $12,000 prizes (with one winner in each county in Oregon), while Oregonians aged 12 to 17 years will have a chance to win one of five CAD $120,000 Oregon College Savings Plan scholarships.
  • Across the 10 international jurisdictions, the type of incentives used for encouraging COVID-19 vaccination are similar to the prizes and awards on offer in the US. Restrictions in access to public and private spaces (e.g., Israel, Saudi Arabia, United Arab Emirates) and disincentives in the form of fines (e.g., Indonesia) have also been implemented.
• Target Population: In general, COVID-19 vaccine incentive programs in the US were designed to be universal, but focus groups and surveys suggest that the most reluctant, least motivated, and/or vaccine-hesitant individuals skew younger, male, and/or Republicans.
• Effectiveness: Preliminary outcomes of COVID-19 vaccine incentive programs in Ohio, California, and Oregon suggest a decrease in the number of vaccines administered despite the announcement of lotteries. For example:
  • In Ohio, in the week following the announcement, vaccination numbers increased during the two weeks following the lottery announcement on May 12, 2021 when compared with the week prior to the announcement. Though Ohio does not track the motive of those getting the vaccine, officials said the boost in vaccination was promising. However, vaccinations dropped by about a quarter in the following week, and again by almost a half the week after that.

Canadian Scan

Information was available on COVID-19 vaccine incentive programs for Alberta, Manitoba, and Nunavut. 

• Incentive Type/Size: Vaccine lottery programs were launched in all three jurisdictions.
  • On June 14, 2021, Alberta offered residents 18 years and older the chance to win one of three CAD $1 million prizes as part of its ‘Open for Summer’ lottery. Since then, the province has since expanded the incentive structure and is now offering several additional travel-related prizes (e.g., vacation packages, vouchers for business- and economy-class flights).
  • On June 9, 2021, Manitoba announced the financial incentives of CAD $2 million in cash and scholarships to encourage people to get vaccinated. Two draws will be held: 1) all Manitobans aged 12+ years who have received at least one dose of vaccine by August 2, 2021 will be eligible for the first draw; and 2) Manitobans aged 12+ years who have received two doses by September 6, 2021 will be eligible for the second draw.
  • In January 2021, the municipality of Arviat, Nunavut (approximately 3,000 people) encouraged residents to get vaccinated by offering the chance to win one of five CAD $2,000 prizes.
• Target Population: The programs were designed to be universal.
• Effectiveness: The evidence for whether lotteries are inspiring Manitobans and Albertans to get vaccinated is mixed:
  • As of June 17, 2021, a spokesperson for Manitoba said there has been a ‘slight uptick’ in first doses since the announcement was made but analysis is still ongoing.
  • As of June 16, 2021, the day after the lottery was announced in Alberta, the province has recorded its three lowest number of first vaccine tallies since February 2021. 

Ontario Scan

• No information was identified.