Harsha Thirumurthy is an Associate Professor in the Department of Medical Ethics and Health Policy at the University of Pennsylvania. He is also Associate Director at the Center for Health Incentives and Behavioral Economics and a Research Associate at Penn’s Population Studies Center. Professor Thirumurthy’s interests lie at the intersection of economics and public health. A major goal of his research is to use insights from economics and psychology to design and evaluate interventions that can improve health outcomes in low-income settings. His research has also studied the economic impacts of large-scale health initiatives.
Dr. Thirumurthy has led numerous randomized trials of behavioral interventions, particularly in sub-Saharan Africa and South Asia. He has published peer-reviewed articles in leading journals in economics, public health, and medicine, including JAMA, The Lancet HIV, PLOS Medicine, the New England Journal of Medicine, the Journal of Public Economics, and the American Economic Journal-Applied Economics. Dr. Thirumurthy completed a Ph.D. in economics at Yale University. He is an Affiliate of the Bureau for Research on the Economic Analysis of Development and Chair of the Population Sciences review panel at the National Institute of Child Health and Human Development.
(September 2019). Effect of a Prize-Linked Savings Intervention on Savings and Healthy Behaviors among Men in Kenya: A Randomized Clinical Trial. JAMA Network Open, 2(9), e1911162.
Importance Interventions to reduce men’s alcohol use and risky sexual behaviors are essential for reducing new HIV infections in high-prevalence settings in sub-Saharan Africa. Prize-linked savings accounts can motivate savings and may decrease expenditures on risky behaviors, but few studies have examined the HIV prevention potential of such savings interventions among men.
Objective To evaluate the effect of prize-linked savings accounts on savings behavior and expenditures on alcohol, gambling, and transactional sex among men in Kenya.
Design, Setting, and Participants Randomized clinical trial among communities in Siaya County, Kenya. Participants were men 21 years or older who owned a mobile phone were engaged in fishing or transportation sector work, and were willing to open an account with a local bank; they were screened for eligibility between September 3 and October 5, 2018.
Interventions Eligible participants were offered savings accounts endowed with 1000 Kenya shillings (US $10) and randomized (1:1) to receive weekly lottery-based rewards contingent on growth in savings balance or to a control group that received standard interest.
Main Outcomes and Measures The primary outcome was an indicator of whether a participant saved any money in the bank account (intent-to-treat analysis) during the study period. Secondary outcomes included the total amount saved in the bank account, the total amount saved in all sources, and expenditures on alcohol, gambling, and transactional sex.
Results A total of 425 men were screened, 329 (77.4%) met eligibility criteria, 300 (70.6%) were enrolled (with 152 randomized to the intervention group and 148 to the control group), and 270 of 300 (90.0%) opened bank accounts. Participants’ mean age was 33.7 years (interquartile range, 13.5 years), 84.3% (253 of 300) were married, and the mean weekly earnings were US $30 (interquartile range, US $23). During a mean (SD) follow-up of 9 (2) weeks, 37.3% (50 of 134) in the intervention group saved money in a bank account vs 27.2% (37 of 136) in the control group, although the difference was not statistically significant (odds ratio, 1.62; 95% CI, 0.96-2.74). The intervention group had higher growth in bank savings balances (US $10.26; 95% CI, US $5.00-US $58.20 vs US $4.87; 95% CI, US $0.67-US $9.00) and higher total savings from all sources (US $201; 95% CI, US $133-US $269 vs US $145; 95% CI, US $88-US $202), but neither difference was statistically significant. The intervention did not have a significant effect on alcohol, gambling, and transactional sex expenditures.
Conclusions and Relevance Prize-linked savings accounts modestly increased savings among high-risk men in Kenya over a 9-week period, but the difference compared with standard-interest savings accounts was not significant. Testing of more powerful savings products is needed to assess whether such savings-led interventions can reduce men’s expenditures on alcohol, gambling, and transactional sex.
(August 2019). Effect of Prices, Distribution Strategies, and Marketing on Demand for HIV Self-Testing in Zimbabwe: A Randomized Clinical Trial. JAMA Network Open, 2(8), e199818.
Greater awareness of HIV status and more frequent testing in high-risk populations are essential for realizing the promise of treatment as prevention and achieving the 90-90-90 targets of the Joint United Nations Programme on HIV/AIDS (that by 2020, 90% of people living with HIV will know their HIV status, 90% of people with diagnosed HIV will be on antiretroviral therapy [ART], and 90% of people receiving ART will be virally suppressed).1 Yet in sub-Saharan Africa, nearly 20% of people living with HIV were unaware of their status in 2017.2 Despite the scale-up of a clinic- and community-based models for providing HIV testing services, testing coverage remains suboptimal, particularly among men and other key populations.3 To close the testing gap and advance HIV prevention objectives, innovative approaches are needed to increase the uptake of HIV testing in sub-Saharan Africa.
A self-administered test for HIV allows individuals to collect their own sample and to perform a simple, rapid HIV antibody test in the absence of a health care practitioner.4 Several oral fluid-based or blood-based HIV tests have received prequalification from the World Health Organization and showed high sensitivity and specificity among lay users.4 Existing research shows high interest in and acceptability of HIV self-testing across a wide range of populations.5–12 After the 2016 World Health Organization guidelines that recommended large-scale implementation of HIV self-testing, self-tests are becoming more widely available in governmental health facilities and retail outlets in several countries in sub-Saharan Africa with high HIV prevalence.4
Donor agencies and governments have heavily subsidized HIV self-tests for distribution in some countries, and private sector availability is emerging in parallel.13 However, the cost of self-tests and the price for consumers represent important obstacles to large-scale implementation of HIV self-testing. As countries seek to scale up HIV self-testing for priority populations, little evidence exists on the effect of alternative pricing and marketing strategies on self-testing demand. A growing body of evidence from low-income countries shows that demand for prevention technologies, such as antimalarial bed nets and water filtration solutions, is highly price sensitive.14–19 Knowing the self-testing demand at various prices in the general population and key subgroups is important for setting appropriate subsidy levels for these self-tests and for understanding the demand for HIV prevention technologies in general. Moreover, with HIV self-testing, information is limited about the optimal distribution approaches for reaching untested individuals and messaging strategies for promoting the adoption of such new technologies. Estimating how demand is affected not only by prices but also by various distribution approaches and types of information provided to consumers can further inform HIV self-testing scale-up efforts.
We conducted a large community-based randomized clinical trial to examine the optimal pricing policies and distribution strategies for HIV self-testing in Zimbabwe.
(March 2019). The Uncertain Effect of Financial Incentives to Improve Health Behaviors. JAMA: The Journal of the American Medical Association, 321(15), 1451-1452.
If intrinsic motivations alone were enough to influence health behaviors, individuals would not smoke, all drivers would wear seat belts, and patients with chronic conditions would take their medications. Yet approximately half of patients prescribed single-drug therapy for hypertension discontinue their medications within a year,¹ even though presumably they want to avoid strokes and hopefully know that taking their medication is one way to reduce health risks.
To supplement the intrinsic motivations apparently insufficient to the task, economists and others have long proposed extrinsic motivations in the form of financial rewards. These rewards offer the added benefit of being immediate rather than the typically delayed intrinsic rewards of better health sometime in the future. Studies in varied health domains have revealed that financial incentives work well.
For example, a 2015 systematic review determined that to reduce smoking during pregnancy, financial or material incentives were more effective than other medical or behavioral strategies.² The use of incentives is also widespread. In 2018, 86% of US employers offered some financial incentives for healthy behavior,³ and in lower-income countries, conditional cash transfer programs rewarded utilization of preventive services.