Pay-it-forward as a strategy to increase vaccine uptake

An article in BMC Global and Public Health examines the pay-it-forward strategy as a promising solution to increase vaccine uptake by encouraging individuals who receive subsidies or free vaccines to donate for future recipients, fostering community engagement and trust in vaccine services. The article also looks at the challenges in scaling up and sustaining this strategy which should be addressed through future large-scale implementation trials.

Core Mechanism

A 3-component approach combining:

  1. Financial support: Subsidized/free vaccines funded by community donations.

  2. Education: Culturally tailored messages (e.g., postcards, digital content) addressing knowledge gaps.

  3. Reciprocity: Recipients “pay forward” gifts/donations for future beneficiaries, fostering community trust.

Evidence of Effectiveness

  • HPV vaccination (China RCT): 34% uptake in pay-it-forward vs. 18% in standard care; reduced vaccine delays by 17%.

  • Influenza vaccination (quasi-experimental): 74% uptake vs. 37% in control; significantly higher confidence in vaccine safety/importance.

  • Key driver: Upstream reciprocity—78% of participants cited community solidarity as motivation.

Practical Implementation for MICs

  • Address dual barriers:

    • Use subsidies for affordability (especially for user-fee vaccines like HPV).
    • Leverage peer messages (e.g., postcards, social media) to combat hesitancy.

  • Adapt delivery:

    • Collectivist settings: Frame around community responsibility.
    • Digital integration: Use apps/social media to reduce staffing needs (pilot-trial ongoing: ChiCTR2300079291).

  • Sustainability: Partner with local NGOs for transparent fund management (covers 13–32% of costs in trials).

Key Challenges & Mitigation

Challenge Solution for MICs
Cultural acceptability Co-design messaging with communities
Staff/time intensity Digital tools + integrate with existing campaigns
Financial viability Hybrid financing: Combine with govt subsidies

Use Cases & Scalability

  • Priority contexts: Migrant populations, rural areas, user-fee vaccines.

  • Transitional role: Complements (but doesn’t replace) govt programs during UHC expansion.

  • Next steps: Test in routine immunization systems; evaluate long-term behavior change.