Appointments: Overcoming Behavioural Barriers to Healthcare

Researchers: Laura Derksen, Jason Kerwin, Natalia Ordaz Reynoso, Olivier Sterck

In rich countries, almost all healthcare is by scheduled appointment. Indeed, appointments are often logistically necessary from the point of view of providers. 
In poor countries, on the other hand, health appointments are surprisingly rare. Everything from prenatal care to HIV testing is offered on a walk-in basis. 
At the same time, people often put off seeking healthcare, especially when it is not urgent. For example, even though high quality HIV treatment is free at clinics, HIV testing rates are low in many African countries.

How do health appointments affect the behavior of patients? Do they actually encourage people to seek care?

Appointments could affect patient behaviour in a few ways. First, they are convenient: if you have an appointment you probably do not have to wait around. Second, appointments might help you overcome forgetfulness, procrastination, or self control problems. Appointments make a particular date salient in your mind, and often come with reminders. They also come with an element of social pressure: someone has put aside a time to see you and is expecting you to show up.

Here, we wanted to test whether appointments encourage people to seek an HIV test. We ran a randomized experiment in Malawi, an HIV-endemic country in southern Africa. We focused on a population with both a high risk of infection and a low rate of HIV testing: men hanging out at urban bars. 

We offered HIV testing appointments to half of 1200 participants, with the other half serving as a control group. The appointments meant no wait time, a phone call reminder, and that a health worker would be waiting at the clinic for you to show up.

Health appointments turned out to be incredibly effective as a behavioural tool. Men who were offered an appointment were three times more likely to get tested for HIV than men who were not. 

We also compared appointments to a classic commitment device. Commitment devices are often proposed as a tool to help people overcome self control problems. They involve putting some money down, that you will only get back if you follow through on a particular commitment. In our case, you'd only get it (about $2) back if you came to the clinic.

While the commitment device did help, appointments were much more effective, and no one had to lose any money. 

Health appointments are a very attractive behavioural tool. They're win-win: convenient for providers and for patients. They are easy and inexpensive to implement, especially as mobile phones become more common worldwide.

As supply picks up, countries are going to stop rationing COVID vaccines. Instead, policy makers will have to start thinking about how to reach those who think they are low risk, or prone to procrastination. When appointments are no longer necessary from the supply side, they might still be quite useful, if only to make sure people keep showing up.