A System for Cash Rewards in the Global Eradication Program for Guinea Worm Disease
October 8, 1993
Dr. Anders R. Seim
Health & Development International
A cash-reward system is being offered to the global GuineaWorm Eradication Program, for use in countries which have only a few cases of guinea worm disease within their boundaries, and countries with a history of endemic dracunculiasis.
This document describes the principles of the reward system, general selection criteria for nations and individuals etc. As the National Guinea Worm Eradication Programs varies from country to country, details are expected to be worked out individually with each eligible nation.
It is of course up to the National Guinea Worm Eradication Program in each nation to decide whether they wish to use the reward system. Countries choosing to use the system would decide whether they will pay rewards just to patients or also to village volunteers or others, as described below.
The idea is to budget $1,000 or $2,000 / eligible country / year in local currency, depending on whether rewards are offered only to the patients, or also to village volunteers. The reward system, including selection criteria for eligibility of nations and of patients within nations, was developed in close collaboration with endemic countries and with the WHO Collaborating Center.
As the number of cases is reduced, and in nations which introduce the HDI-guinea worm reward at lower levels of endemicity, the reward per case can be increased within the total budgeted for each country.
HDI will offer the reward to each of the eligible nations on a year-by-year basis. Our donors have committed themselves to finance The HDI Guinea Worm Reward for the duration of the eradication effort, so the year-by-year commitment will depend only on proper application of funds provided, and the continued fulfillment of selection criteria.
- To reduce the time and expense required to successfully complete the eradication of guinea worm disease, in nations which have only a few cases left.
- To increase the sensitivity of active surveillance.
- To help guard against concealment of cases.
Selecting Nations for introducing HDI Guinea Worm Rewards
NUMBER OF CASES
There should be about 500 cases of guinea worm or less in the country, ascertained by adequate, nationwide, active surveillance. In Nigeria, the figure may be 500 in a single zone.
In situations where only very few or no cases are expected to exist in a country, the reward system may be introduced as part of the surveillance system from the very start. For example, one may offer $100 for the first 10 cases in the nation, limited to one patient/village.
FUNCTIONING CASE CONTAINMENT SYSTEM
The country must have a system for case-containment, which is already established and well functioning. The case-containment system must be such that reports of cases are rapidly transmitted to trained health workers in the guinea worm program (nationally,or at a central sub-national level); these health workers must be able to personally confirm each reported case; the arrangements for case-containment must provide for measures which will ensure that no further transmission occurs from each case which has been identified.
In countries using HDI Guinea Worm Rewards as part of their original national case search, case containment must nevertheless be provided for.
The country must agree to publicize the rewards widely, since the reward will not be effective unless most people in endemic areas know about it. Pictures of guinea worm can be shown in printed media, TV, and on posters, with broad coverage also given via radio broadcasts.
We hope the government itself, the media, UNICEF and other UN agencies, bilateral assistance agencies, and other supporters of guinea worm eradication can help in the task of making the guinea worm reward widely known. We expect broad publicity will be easier to achieve, the larger the reward being offered. We believe that guinea worm rewards of some size will be considered highly newsworthy by the media themselves.
ADEQUATE FINANCIAL CONTROL
There must be an agreement between the national guinea worm eradication program and the WHO Representative (or some other external collaborating agency), which assures the donors that adequate financial control is being exercised and to guarantee that rewards are only paid upon the fulfillment of the relevant criteria for the selection of individuals. Paid rewards must be accounted for in detail, also for the purpose of assuring optimal case surveillance.
Each recipient of The HDI Guinea Worm Reward must in some way sign a receipt for the money. The national guinea worm eradication program must forward these receipts to HDI, via the WHO Representative or whichever collaborating agency may be acting in lieu of WHO for this purpose.
Along with the receipts for each year, the program manager must send a note listing the names of those who got the reward, what village each of them lives in, where each is believed to have been infected, and other particulars of each case including which case containment measures were taken.
These receipts and such a note from the national program manager are a prerequisite for releasing funding for the next year.
LOW RISK OF IMPORTED CASES
In some situations, nearby areas in neighboring countries may have a substantially higher number of cases than the country which is to start implementing the reward system.
The reward system will only work well if it is widely publicized and known. It is important to guard against situations where people might cross from a neighboring country with a much higher number of guinea worm cases, to collect a reward in the country with few cases.
Selecting Individuals for HDI Guinea Worm Rewards
He or She Must Have Guinea Worm
The patient must have one or more confirmed guinea worms. In some areas, larger rewards could be offered for patients reported before the worm begins to emerge.
The case must be verified by one or more adequately trained health workers from the national guinea worm eradication program, at the national or a central sub-national level.
Help Determine Place of Infection
The patient must cooperate in assisting the guinea worm eradication program to reconstruct his/her travel during the previous year, so that one may try to determine where the patient might have been infected.
The patient must submit to adequate containment measures, e.g. surgical extraction or alternatively, controlled immersion and/or occlusive bandaging followed by adequate control until all the patient’s worms are completely out, in accordance with the nation’s plan of action, to assure that further transmission does not occur.
Payment of the Reward
Payment of the reward should be made promptly when all of the above criteria have been met.
THE VILLAGE WORKERS (AND OTHERS):
In countries wishing to do so, the reward system provides for cash rewards or “incentives” to the village volunteer or any other individual who brings the case to the attention of the guinea worm eradication program.
The total amount available for payment to anyone other than the patient, will be no more than the reward to the relevant case.
To be eligible for a reward/incentive, the village worker must report the case promptly, for example within 24 hours of finding the case or some other time-limit chosen at the national level.
Countries may decide to offer larger rewards when the case is reported before worm emergence than after the worm has begun to penetrate through the skin.
Ensure Case Containment Until the Case is Verified
The village worker must ensure that the patient is available for case-verification without contaminating any new water sources, until the case can be confirmed and adequate containment measures are taken.
This can be done by bringing the patient directly to the verifying-person, or by otherwise ensuring that the patient does not contaminate any water source until the verifying-person can reach the village (within a very few days of receiving the report).
Timing of the Reward/Incentive
The reward/incentive to the village worker is eligible to be paid when the patient has received his/her reward and where the above criteria are fulfilled. When possible, this should be paid at the same time as the patient is paid; if not, the patient shall have first priority.
Presently, we only expect to be able to offer rewards up to a total of $1,000 for patients, and $1,000 for village workers and others, for any country in any given year. This means that that each reward would only be equivalent to about $2.00 in countries having about 500 cases.
It has been suggested that $2.00 may be too small an amount to serve as an incentive under any circumstances. Unfortunately, we currently expect to be constrained by the limit of $1,000/eligible nation/year for patients, and a similar amount for village volunteers or others.
Costs for getting the patient to the verifying-person and containment measures must come from the ordinary program budget or some other source. Such case-containment interventions in this mopping-up phase of the program would presumably be instead of other interventions previously offered to the population by the National Guinea Worm Eradication Program.
HDI will transfer the budgeted amount for one year at a time, to the WHO Representative (or other collaborating agency) in eligible nations wishing to implement HDI Guinea Worm Rewards.
Countries already offering rewards, may individually discuss other and flexible ways of using this reward system. They may wish to use HDI Guinea Worm Rewards in areas not currently covered. Or they may wish to combine the amount offered through this reward system with resources already available, to increase the size of the rewards being offered. Countries which have not yet established a reward system will have priority, if any constraints impinge on our ability to supply these rewards to all countries wishing to use them.
This system may be used as a supplement to, not any replacement of funding already available for rewards in a country. Similarly of course, nations may secure additional funding from other sources to supplement what we are able to offer through this particular system.